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Understanding Selective Mutism
COURTNEY KEETON, PHD
CLINICAL PSYCHOLOGIST
ASSISTANT PROFESSOR OF PSYCHIATRY
THE JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE
DECEMBER 3 2012
Questions Addressed
Is selective mutism (SM) the same as shyness?
Does SM go away over time, or is treatment needed?
What are behavioral treatments for SM?
What is the role of the school in SM treatment?
When should medication be considered?
How do I effectively parent my child with SM?
C Keeton PhD
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What Is Selective Mutism (SM)?
The consistent failure to speak in social situations
when speaking is expected
Fluid speech in other situations (usually home & familiar
settings)
Interferes with academic & social development
Duration: at least one month (not September!)
Not due to lack of knowledge/comfort with the language
Not better accounted for by communication or
developmental disorder, or psychosis
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Diagnostic Classification
DSM-IV-TR (2000)
Selective Mutism
DSM-5 (May 2013)
Social Anxiety Disorder (Selective Mutism)
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Clinical Presentation
Large individual variation in communication
behaviors
Context: school, home, public
People: peers, adults, family, strangers
Nonverbal Features: gestures, nods, eye contact
Verbal Features: volume, quantity, spontaneity
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Epidemiology
1 out of 140 kids (0.7%)
Comparable to other anxiety disorders such as OCD
Gender difference: mixed data
Preschool age of onset: before age 5
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Referrals typically made between 6.5 and 9 years of
age
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Course
MYTH: Child will “outgrow it”
Chronic
1/3 remission
1/3 remarkably improved
1/3 minimal improvement
Risk for future impairment
Social Anxiety Disorder
Social skills deficits
Mood problems
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Etiology
Familial/Genetic component
Family history of SM, shyness, anxiety
Temperament
Behavioral inhibition
Environmental vulnerability
Less socially active family
Autonomy-limiting parenting
Negatively reinforced behavior
MYTH: trauma → SM
Insidious onset
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Other Common Concerns
Other forms of anxiety
Social phobia (>80%)
Separation anxiety (~30%)
Specific phobia (~15%)
Generalized anxiety disorder (~15%)
Physical symptoms
Elimination problems (~30%)
Constipation
Enuresis
Encopresis
Oppositional behavior
Communication disorders
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Assessment
Observational methods
Interviewing
Pencil-and-paper questionnaires
Speech and language assessment
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Treatment
Psychosocial Treatment
Pharmacological Treatment
Goals
Reduce anxiety
Increase quality and quantity of speech across people and
situations
Achieve remission: spontaneous, age appropriate
conversational speech across contexts
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Psychosocial Treatment Approaches
First-line treatment = behavioral and cognitive-
behavioral approaches
Cognitive Behavioral Therapy
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Basis of Psychological Problems
Interpersonal
and
environmental
contexts
Emotions
Cognition
Physiology
Behavior
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Features of CBT
Time-limited
Skill-based, problem-specific, goal-oriented
Structured (but flexible)
Present and solution-focused
Collaborative
Empirically-based (data shows it works!)
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CBT for SM
Anxiety
Anxious
Beliefs
Physiology
Avoidant Behavior
Accommodation by
Others
Parenting
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CBT for SM
Avoidant
Behavior
Accommodation
by Others
Parenting
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Targeting Avoidant Behavior
Techniques: Graduated Exposure, Shaping, Stimulus
Fading
Read short story aloud
Ask questions during “Guess Who”
Whisper counting during “Chutes & Ladders”
Mouth the names of pictures/colors during game
Show home video of self talking to doctor
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Targeting Accommodation by Others
Reduce
“mind-reading” in low stress situations
Allow child a chance to respond before repeating
a question
Create opportunities for speech
Stay involved in social activities (swimming,
birthday parties)
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Targeting Parenting Behaviors
Create structure/routine
Encourage independence in child
Offer praise/rewards for positive behaviors
Increase child’s control during play by narrating
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Intervening at School Level
Collect teacher feedback
Provide education
Secure services through an Individualized Education
Plan (IEP) or Section 504 Plan if appropriate
Enlist teacher help in defining and measuring daily
speech goals
Consider use of daily report card
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Sample Daily Report Card (Advanced)
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Pharmacologic Treatment
Recommended when psychosocial interventions are
ineffective or when symptoms are chronic and severe
First-line treatment = Selective Serotonin Reuptake
Inhibitors
Fluoxetine (most studied)
Sertraline
Paroxetine
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Conclusions
Is SM just shyness?
A formal diagnosis suggests a problem that has been ongoing,
present in numerous situations, and causing impairment
My child has SM. Is treatment needed?
The majority of cases don’t resolve without intervention. In
cases when SM “goes away,” there is high risk that anxiety
persists.
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Conclusions
Why are behavioral interventions recommended?
SM is maintained by avoidant behavior, and data suggests that
SM can be effectively treated by learning healthy coping and
approach behaviors in a gradual way.
Does the school need to be involved?
School is typically where the symptoms are most severe, so
interventions need to be applied in the school. Treatment is
most successful when school personnel are aware of the
problem and part of the treatment collaboration.
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Conclusions
When should medication be considered?
Data suggests that SSRIs are well-tolerated and effective in
pediatric populations. These medications should be considered
in treatment resistant cases, when symptoms are severe, or
when additional anxiety or other problems exist.
How to I effectively parent my child with SM?
Be his/her biggest advocate. Understand that SM is not a
voluntary phenomenon, and that progress is gradual.
Collaborate with your child to make a plan. Praise brave
speech and independent behavior.
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Courtney Keeton, PhD
The Johns Hopkins University School of Medicine
Department of Psychiatry
Division of Child & Adolescent Psychiatry
Phone: 410-614-5174
Email: [email protected]
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