To begin with, it is critical to assess symptoms of ASD during the diagnostic evaluation of children who do not speak in specific social situations. To conduct such assessment in an effective and economic way, a two-step procedure as described by Volkmar et al 68 could be adopted. This procedure consists of a first screening of ASD symptoms by means of a scale that has been specifically developed for this purpose eg, the Social Communication Questionnaire , 69 followed by a more extensive diagnostic evaluation by means of the Autism Diagnostic Observation Scale ADOS 70 and the Autism Diagnostic Interview ADI , 71 which are currently considered the gold standard assessment instruments for establishing ASD.
The use of more objective measures such as the ADOS and ADI is not only helpful to establish the presence of autistic features in children with SM but could also identify children who only have SM and who are currently — by some clinicians — erroneously labelled as cases of ASD. The delivery of the regular CBT intervention needs to be optimized by increasing the use of visual aids, providing more structure, incorporating extra sessions, and adding more relaxation exercises.
For example, Pallathra et al 73 noted that individuals with ASD show specific impairments in social cognition, social skills, and social motivation, all of which require attention during treatment. Moreover, the often inflexible and rigid behavior of children with ASD may also require clinical attention, either by specific behavioral interventions or by prescribing antipsychotic medication.
SM is a rare but debilitating disorder that has puzzled researchers and clinicians for a long time. Empirical insights indicate that SM is mainly fear- and anxiety-driven and as such clinicians need to approach the condition as an anxiety disorder.
Meanwhile, the cautionary note has to be made that this may not be the full story. As pointed out by various authors, 74 , 75 SM is likely to be a heterogeneous disorder. This means that while in some children fear and anxiety may be the sole basis of non-speaking behavior in specific social situations, there are other children for whom other psychopathologies and difficulties contribute to the etiology and expression of SM.
In this brief article, we have discussed the examples of speech and language problems, developmental delay, and autism spectrum disorder in the hope that clinicians will address these factors in their assessment, and ultimately deploy the most optimal treatments in children with SM.
National Center for Biotechnology Information , U. Psychol Res Behav Manag. Published online Feb Peter Muris 1, 2 and Thomas H Ollendick 3, 4. Author information Article notes Copyright and License information Disclaimer. Received Dec 27; Accepted Feb 3. This work is published and licensed by Dove Medical Press Limited. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.
For permission for commercial use of this work, please see paragraphs 4. This article has been cited by other articles in PMC. Abstract Selective mutism SM is a childhood disorder characterized by a consistent failure to speak in specific social situations eg, school despite speaking normally in other settings eg, at home. Keywords: selective mutism, anxiety disorder, assessment, treatment.
Introduction Selective mutism SM is a psychological condition usually occurring during childhood that is characterized by a total absence of speech in specific social situations while speech production appears to be normal in other situations. Treatment With the acknowledgement that SM primarily is a fear- and anxiety-driven problem, it is good to see that — at least in the scientific literature — cognitive-behavioral therapy CBT is generally recognized as the most feasible intervention for children with this disorder.
Open in a separate window. Figure 1. Note : Data from these studies. Speech and Language Problems and Developmental Delay One case in point are speech and language problems, which have been shown to be present in a considerable proportion of children with SM.
Autism Spectrum Problems Although the presence of autism spectrum disorder ASD is considered as an exclusion criterion of SM, the more dimensional approach of psychopathology taken by the current DSM-5 1 makes it difficult for clinicians to establish a clear boundary between these two conditions.
Conclusion SM is a rare but debilitating disorder that has puzzled researchers and clinicians for a long time. Disclosure The authors report no conflicts of interest in this work. References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. World Health Organization. International classification of diseases for mortality and morbidity statistics 11th revision ; Accessed February4, Selective mutism: a review and integration of the last 15 years.
Clin Psychol Rev. A follow-up study of 45 patients with elective mutism. Eur Arch Psychiatry Clin Neurosci.
A long-term outcome study of selective mutism in childhood. J Child Psychol Psychiatry. Kussmaul A. Basel, Switzerland: Benno Schwabe; Tramer M. Elektiver Mutismus bei Kindern Elective mutism in children. Z Kinderpsychiatr. Anxiety in children with selective mutism: a meta-analysis. Child Psychiatry Hum Dev.
Fears and fear-related cognitions in children with selective mutism. Eur Child Adolesc Psychiatry. Selective mutism and temperament: the silence and behavioral inhibition to the unfamiliar. Similarities and differences between young children with selective mutism and social anxiety disorder. Behav Res Ther. Children of few words: relations among selective mutism, behavioral inhibition, and social anxiety symptoms in 3- to 6-year-olds.
Kagan J. New York: Routledge; Behavioral inhibition and the risk for developing social anxiety disorder: a meta-analytic study. Ollendick TH, Benoit K. A parent-child interactional model of social anxiety disorder in youth. Clin Child Fam Psychol Rev.
Selective mutism and anxiety: a review of the current conceptualization of the disorder. J Anx Disord. Social anxiety disorder: questions and answers for DSM-V. Depress Anxiety. Selective mutism: the fraternal twin of childhood social phobia. Characterizing selective mutism: is it more than social anxiety? Distinguishing selective mutism and social anxiety in children: a multi-method study.
Selective mutism: more than social anxiety? New York: Graywind; The development and psychometric properties of the Selective Mutism Questionnaire. J Clin Child Adolesc Psychol. Selective Mutism Questionnaire: measurement structure and validity. The Selective Mutism Questionnaire: data from typically developing children and children with selective mutism. Clinical Child Psychology and Psychiatry. It's important for selective mutism to be recognised early by families and schools so they can work together to reduce a child's anxiety.
Staff in early years settings and schools may receive training so they're able to provide appropriate support. If you suspect your child has selective mutism and help is not available, or there are additional concerns — for example, the child struggles to understand instructions or follow routines — seek a formal diagnosis from a qualified speech and language therapist. You can contact a speech and language therapy clinic directly or speak to a health visitor or GP, who can refer you.
Do not accept the opinion that your child will grow out of it or they are "just shy". Older children may also need to see a mental health professional or school educational psychologist. The clinician may initially want to talk to you without your child present, so you can speak freely about any anxieties you have about your child's development or behaviour.
They'll want to find out whether there's a history of anxiety disorders in the family, and whether anything is causing distress, such as a disrupted routine or difficulty learning a second language.
They'll also look at behavioural characteristics and take a full medical history. A person with selective mutism may not be able to speak during their assessment, but the clinician should be prepared for this and be willing to find another way to communicate. For example, they may encourage a child with selective mutism to communicate through their parents, or suggest that older children or adults write down their responses or use a computer.
It's possible for adults to overcome selective mutism, although they may continue to experience the psychological and practical effects of spending years without social interaction or not being able to reach their academic or occupational potential. Adults will ideally be seen by a mental health professional with access to support from a speech and language therapist or another knowledgeable professional.
Selective mutism is diagnosed according to specific guidelines. These include observations about the person concerned as outlined:. A child with selective mutism will often have other fears and social anxieties , and they may also have additional speech and language difficulties. They're often wary of doing anything that draws attention to them because they think that by doing so, people will expect them to talk. For example, a child may not do their best in class after seeing other children being asked to read out good work, or they may be afraid to change their routine in case this provokes comments or questions.
Many have a general fear of making mistakes. Accidents and urinary infections may result from being unable to ask to use the toilet and holding on for hours at a time.
School-aged children may avoid eating and drinking throughout the day so they do not need to excuse themselves. Children may have difficulty with homework assignments or certain topics because they're unable to ask questions in class.
Teenagers may not develop independence because they're afraid to leave the house unaccompanied. And adults may lack qualifications because they're unable to participate in college life or subsequent interviews. With appropriate handling and treatment, most children are able to overcome selective mutism. But the older they are when the condition is diagnosed, the longer it will take. Treatment does not focus on the speaking itself, but reducing the anxiety associated with speaking.
This starts by removing pressure on the person to speak. They should then gradually progress from relaxing in their school, nursery or social setting, to saying single words and sentences to one person, before eventually being able to speak freely to all people in all settings. The need for individual treatment can be avoided if family and staff in early years settings work together to reduce the child's anxiety by creating a positive environment for them.
As well as these environmental changes, older children may need individual support to overcome their anxiety. The most effective types of treatment are cognitive behavioural therapy CBT and behavioural therapy.
Cognitive behavioural therapy CBT helps a person focus on how they think about themselves, the world and other people, and how their perception of these things affects their thoughts and feelings.
CBT also challenges fears and preconceptions through graded exposure. CBT is led by mental health professionals and is more appropriate for older children, adolescents — particularly those experiencing social anxiety disorder — and adults who've grown up with selective mutism. Younger children can also benefit from CBT-based approaches designed to support their general wellbeing. For example, this may include talking about anxiety and understanding how it affects their body and behaviour and learning a range of anxiety management techniques or coping strategies.
Behavioural therapy is designed to work towards and reinforce desired behaviours while replacing bad habits with good ones. Rather than examining a person's past or their thoughts, it concentrates on helping combat current difficulties using a gradual step-by-step approach to help conquer fears.
There are several techniques based on CBT and behavioural therapy that are useful in treating selective mutism. Parents will often comment how boisterous, social, funny, inquisitive, extremely verbal, and even bossy and stubborn these children are at home! What differentiates most children with Selective Mutism is their severe behavioral inhibition and inability to speak and communicate comfortably in most social settings. Some children with Selective Mutism feel as though they are on stage every minute of the day!
This can be quite heart-wrenching for both the child and parents involved. Often, these children show signs of anxiety before and during most social events.
Physical symptoms and negative behaviors are common before school or social outings. It is important for parents and teachers to understand that the physical and behavioral symptoms are due to anxiety and treatment needs to focus on helping the child learn the coping skills to combat anxious feelings.
It is common for many children with Selective Mutism to have a blank facial expression and never seem to smile. Many have stiff or awkward body language when in a social setting and seem very uncomfortable or unhappy. Some will turn their heads, chew or twirl their hair, avoid eye contact, or withdraw into a corner or away from the group seemingly more interested in playing alone.
Others are less avoidant and do not seem as uncomfortable. They may play with one or a few children and be very participatory in groups.
These children will still be mute or barely communicate with most classmates and teachers. Over time, these children learn to cope and participate in certain social settings. They usually perform nonverbally or by talking quietly to a select few.
Social relationships become very difficult as children with Selective Mutism grow older. As peers begin dating and socializing more, children with Selective Mutism may remain more aloof, isolated, and alone.
Children with Selective Mutism often have tremendous difficulty initiating and may hesitate to respond even nonverbally. This can be quite frustrating to the child as time goes by.
Ingrained behavior often manifests itself by a child looking and acting normally but communicating nonverbally. This particular child cannot just start speaking. Treatment needs to center on methods to help the child unlearn the present mute behavior. What are the most common characteristics of children with Selective Mutism? Most, if not all, of the characteristics of children with Selective Mutism can be attributed to anxiety.
When are most children diagnosed as having Selective Mutism? Most children are diagnosed between 3 and 8 years old. In retrospect, it is often noted that these children were temperamentally inhibited and severely anxious in social settings as infants and toddlers, but adults thought they were just very shy.
Most children have a history of separation anxiety and being slow to warm up. Often it is not until children enter school and there is an expectation to perform, interact and speak, that Selective Mutism becomes more obvious. What often happens is teachers tell parents the child is not talking or interacting with the other children.
In other situations, parents will notice, early on, that their child is not speaking to most individuals outside the home. Why do so few teachers, therapists and physicians understand Selective Mutism? Studies of Selective Mutism are scarce. Most research results are based on subjective findings based on a limited number of children. In addition, textbook descriptions are often nonexistent, or information is limited, and in many situations, the information is inaccurate and misleading.
As a result, few people truly understand Selective Mutism. Professionals and teachers will often tell a parent, the child is just shy, or they will outgrow their silence. Others interpret the mutism as a means of being oppositional and defiant, manipulative or controlling. Some professionals erroneously view Selective Mutism as a variant of autism or an indication of severe learning disabilities. For most children who are truly affected by Selective Mutism, this is completely wrong and inappropriate!
Mutism not only persists in these children, but is negatively reinforced. These children may develop oppositional behaviors out of a combination of frustration, their own inability to make sense of their mutism, and others pressuring them to speak.
As a result of the scarcity and often inaccuracy of information in the published literature, children with Selective Mutism may be misdiagnosed and mismanaged. In many circumstances, parents will wait and hope their child outgrows their mutism and may even by advised to do so by well-meaning, but uninformed professionals. However, without proper recognition and treatment, most of these children do NOT outgrow Selective Mutism and end up going through years without speaking, interacting normally, or developing appropriate social skills.
In fact, many individuals who suffer from Selective Mutism and social anxiety who do not get proper treatment to develop necessary coping skills may develop the negative ramifications of untreated anxiety see below. Our findings indicate that the earlier a child is treated for Selective Mutism, the quicker the response to treatment, and the better the overall prognosis.
In other words, Selective Mutism can become a difficult habit to break! Anxiety disorders are the most common mental illnesses among children and adolescents. Our main objective is to diagnose children early, so they can receive proper treatment at an early age, develop proper coping skills, and overcome their anxiety. If parents suspect their child has Selective Mutism, what should they do? However, please note that having experience with Selective Mutism does not guarantee that the treatment approach and understanding is correct.
In fact, a clinician with less experience, yet who has an excellent understanding of Selective Mutism may be an ideal choice for your child. What are the key questions to ask a potential therapist or physician? Do your homework! You will have a much better idea what to look for if you understand Selective Mutism.
Educate yourself as much as possible before seeing any professional. Parents should read as much information as they can about Selective Mutism. The Selective Mutism Association website has countless pages of information and it is updated on a regular basis. Simply lowering anxiety is NOT enough to enable the child to begin engaging socially, learn to progress to verbal communication and feel comfortable in an environment.
Skills must be taught. Treatment approaches based on discipline and forcing a child to speak are inappropriate and will only heighten anxiety and negatively reinforce mute behavior. How is a child evaluated for Selective Mutism? Children suffering from Selective Mutism SM change their level of social communication based on the setting as well as the expectations from others within a setting.
As a result, social comfort and communication will change from setting to setting and person to person. For some children, they appear very comfortable and mutism is the most noted symptom.
This usually means they are able to engage nonverbally with others via astute nonverbal skills professional mimes! These children are stuck in the nonverbal stage of communication Stage 1 and suffer from a subtype of SM called Speech Phobia. Although mutism is the most noted symptom of SM, the inability to speak merely touches on the surface of our children.
A complete understanding of the child is necessary to develop an appropriate treatment plan for home and in the real world, as well as in school by developing accommodations and interventions, e. IEP or Plan.
According to Dr. To help a child suffering in silence, an understanding of which stage the child is in during particular social encounters must be developed. Treatment is then developed via the whole child approach under the direction of the treatment professional, the child, parents, and school personnel working together.
Shipon-Blum emphasizes that although anxiety lowering is key, it is often not enough, especially as children age. Over time, many children with Selective Mutism no longer feel anxious, but their mutism and lack of proper social engagement continue to exist in select settings.
Children with SM need strategies and interventions to progress from nonverbal to spoken communication. This is the Transitional Stage of Communication, an aspect missing from most treatment plans. In other words, how do you help a child progress from nonverbal to verbal communication? Strategies and interventions are developed based on where the child is on the Social Communication Bridge in a particular setting and are meant to be a desensitizing method as well as a vehicle to unlearn conditioned behavior.
Time in the therapy office is simply not enough. The office setting is used to help prepare the child for the school and real world environments by developing strategies to help the child unlearn his or her conditioned behavior.
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