Interactions between parenting styles, child anxiety, and oppositionality in selective mutism.

Selective mutism (SM) is a poorly understood condition, and debate continues regarding its etiology and classification. Research suggests that a genetic vulnerability may play a role in the development of the disorder which may be compounded by anxious and over-protective parenting. While previous studies supported the role of parenting styles in the development of SM, most of them examined child and parent factors in isolation. The current study examined how the interactions between child internalizing and externalizing behaviors (anxiety and oppositionality, respectively) and parenting styles (authoritative, permissive, and authoritarian) are associated with SM diagnosis. The study included 285 children aged 3-7 years (57.2% females), and their parents (66 children with SM and 219 typically developed children). Parents completed questionnaires about child social anxiety, oppositional behavior, SM severity, and their parenting style. Results showed that parents of children with SM reported lower levels of authoritative practices than those of typically developed children. We also found that child social anxiety and oppositionality moderated the effects of authoritative and authoritarian parenting practices on SM diagnosis. Our results suggest that child anxiety and oppositionality may explain the different susceptibility of children to adaptive and maladaptive parenting styles.

Symptoms of selective mutism beyond failure to speak in children and adolescents.

Understanding the symptoms of a mental disorder is essential for accurate diagnosis or selecting appropriate treatment targets. Despite this, there is a surprising lack of systematic research on the symptoms of selective mutism (SM). While the DSM-5 defines failure to speak as the only core symptom of SM, sparse research suggests that children with SM may experience additional symptoms. Previous studies have been limited in their identification of symptoms of SM, either by using a predefined set of symptoms or by only asking for anxiety-specific symptoms. This may have resulted in important symptoms being overlooked. In this study, we provided n = 86 parents of children and adolescents with SM (3-18 years) with a symptom definition appropriate for the target group. Additionally, parents were asked an open-ended question about any other symptoms they had observed in their children, beyond the failure to speak. The symptoms reported were categorized using qualitative content analysis (QCA) and examined for frequency and association with symptom severity. Ten different symptom categories were identified, with fear, freezing, and avoidance/security behaviors being the most prevalent. On average, parents reported M = 4.74 (SD = 2.37) symptoms from different symptom categories. Only fear was found to be related to symptom severity of SM. As the findings suggest that SM encompasses various symptoms beyond failure to speak, a more sophisticated understanding of SM as a mental disorder with multiple symptoms seems essential. The clinical implications of this are discussed in further detail.

Can We Be Creative with Communication? Assessing Decision-Making Capacity in an Adult with Selective Mutism.

Selective mutism is an anxiety disorder in which an individual is unable to speak in certain social situations though may speak normally in other settings (Hua & Major, 2016). Selective mutism in adults is rare, though people with this condition might have other methods of communicating their needs outside of verbal communication. Healthcare professionals rely on a patient's ability to communicate to establish if they have decision-making capacity. This commentary responds to a case of a young adult patient with selective mutism and social anxieties that significantly limited his ability to communicate with anyone in the healthcare team. This required a creative, patient-centered approach to engage in meaningful communication.

Phasic Versus Tonic Irritability and Associations with Family Accommodation Among Youth with Selective Mutism: A Latent Profile Analysis.

Clinical presentations of selective mutism (SM) vary widely across affected youth. Although studies have explored general externalizing problems in youth with SM, research has not specifically examined patterns of irritability. Relatedly, research has not considered how affected families differentially accommodate the anxiety of youth with SM as a function of the child's temper outbursts (i.e., phasic irritability) and general angry mood (i.e., tonic irritability). Data were drawn from a sample of treatment-seeking children and adolescents with a primary diagnosis of selective mutism (N = 152; Mean age = 6.12 years; 67.11% female), and their caregivers. Latent profile analysis (LPA) was used to identify distinct profiles in SM youth that were characterized by varying levels of phasic and/or tonic irritability. Analyses further examined whether these different profiles were associated with different levels of family accommodation and global impairment. LPA identified 5 profiles: SM with No irritability, SM with Low Phasic Irritability, SM with High Phasic Irritability, SM with High Phasic and Moderate Tonic Irritability, and SM with High Phasic and High Tonic Irritability. Patterns of family accommodation and global impairment were highest among youth belonging to profiles characterized by high phasic irritability. Findings highlight separable patterns of irritability across youth with SM, with phasic irritability (i.e., temper outbursts) appearing particularly linked with increased family accommodation and overall global impairment. Assessing phasic irritability is critical for optimizing treatment in youth with SM and can be useful for flagging possible patterns of family accommodation contributing to overall impairment.

It's about more than just talking; Exploring computer-mediated communication in adolescents with selective mutism.

INTRODUCTION: Selective mutism (SM) is an anxiety disorder categorized by a persistent failure to speak in specific situations. In an attempt to facilitate interaction with individuals with SM, other forms of communication (e.g. computer-mediated communication; CMC) are often tried. However, CMC is understudied in individuals with SM, while, especially since the COVID-19 pandemic, the importance of CMC for education and social purposes only increased. METHODS: In this study, we explored CMC in 79 adolescents with either selective mutism (n = 34), or typical development (n = 45). All participants completed a survey concerning verbal and written CMC in three contexts (friends, family, and school). RESULTS: Results showed that adolescents with SM used not only verbal but also written CMC less frequently than the comparison group across contexts. While the comparison group preferred Face-to-Face communication over CMC, adolescents with SM were divided, especially in the school context. With family and friends, the majority of the SM group preferred Face-to-Face communication, even though this provoked more feelings of tension than CMC for part of the group. CONCLUSION: These findings support anecdotal reports that SM affects not only speech but extends to other communicative venues and includes written communication in many situations. This underlines the importance of addressing not just speaking behavior but also writing and CMC in the diagnostic evaluation and treatment plans for adolescents with SM.

Selective mutism in immigrant families: An ecocultural perspective.

Although the diagnosis of selective mutism (SM) is more prevalent among immigrant children, the link between the disorder and an immigration background has been elusive. Guided by ecocultural models of development, the current study aimed to construct a theory-based description of SM while considering individual, family, and contextual risk factors. Participants were 78 children with SM (38.4% with an immigration background), and 247 typically developed children (18.2% with an immigration background). Consistent with previous studies, our results suggest that anxiety was the most important predictor of SM symptoms, above and beyond immigration background. Immigration, especially if coupled with bilingual status and low family income, predicted increased levels of SM symptoms. Identifying multi-level predictors of SM may help researchers and clinicians to improve early identification and treatment of SM in culturally and linguistically diverse children.

Current scenario and potential of music therapy in the management of diseases.

Over the preceding years, music therapy has gained tremendous attention due to new findings of music in management of various conditions like Alzheimer's, depression, anxiety, insomnia, etc. Music is a non-invasive, patient-friendly and pleasant form of therapy with minimal or no side effects. It activates the reward pathway of brain by influencing several processes such as dopamine release, reduction in cortisol levels, increase in estrogen and testosterone levels. This review article focuses on advantages and disadvantages of music therapy, mechanism of action of music in brain and its effective applications in the management of different diseases. The article covers history of music therapy in America, Egypt, and India with practice of music therapy. The advanced effects of music therapy in autism, cancer, post-operative pain, Parkinson's disease, selective mutism, stroke, heart problems, pregnancy, eating disorders, bone fractures and obsessive compulsive disorders are discussed. Also the effect of music therapy on the quality of sleep and brain waves has been discussed. This is an established profession in western countries like America, UK, Australia, and Canada, but not in low-income countries like India where it needs to be standardized.

Remote Intensive Group Behavioral Treatment for Families of Children with Selective Mutism.

Selective mutism (SM) is a relatively rare, but highly interfering, child anxiety disorder characterized by a consistent failure to speak in certain situations, despite demonstrating fluent speech in other contexts. Exposure-based cognitive behavioral therapy and Parent-Child Interaction Therapy adapted for SM can be effective, but the broad availability and accessibility of such specialty care options remains limited. Stay-at-home guidelines to mitigate the spread of COVID-19 further limited the accessibility of office-based specialty care for SM. Building on separate lines of research supporting intensive treatments and telehealth service delivery models, this paper is the first to describe the development, preliminary feasibility, acceptability, and efficacy of a Remote Intensive Group Behavioral Treatment (IGBT) for families of young children with SM (N=9). Treatment leveraged videoconferencing technology to deliver caregiver training sessions, lead-in sessions, 5 consecutive daily IGBT sessions, and an individualized caregiver coaching session. Remote IGBT was found to be both feasible and acceptable. All families (100%) completed diagnostic assessments and caregiver-report questionnaires at four major study timepoints (i.e., intake, pre-treatment, post-treatment, 4-month follow-up) and participated in all treatment components. Caregivers reported high treatment satisfaction at post-treatment and 4-month follow-up and low levels of burden associated with treatment participation at post-treatment. Approximately half of participating children were classified as treatment responders by independent evaluators at post-treatment and 4-month follow-up. Although these pilot results should be interpreted with caution, the present work underscores the potential utility of using videoconferencing to remotely deliver IGBT to families in their natural environments.

Integrated Behavior Therapy for Exclusively Anxious Selective Mutism: A Nonconcurrent Multiple-Baseline Design across Five Participants.

Selective mutism (SM) is a rare childhood anxiety disorder which may be markedly detrimental to a child's academic and social functioning if left untreated. Cognitive-behavioral treatments for social anxiety disorders have been found to be effective for SM, yet a paucity of published studies have explored manualized treatment approaches carried out by novice clinicians. The purpose of the present study was to examine the adherence, effectiveness, and acceptability of a condensed, 16-session version of Integrated Behavior Therapy for Selective Mutism (IBTSM; Bergman, 2013), the first manualized treatment for SM. A nonconcurrent multiple-baseline single-case design was used across five children diagnosed with SM, exclusively anxious subtype. IBTSM was implemented with excellent adherence (M = 98%) over an average of 19 weeks (range = 16-22 weeks). Visual analyses of weekly caregiver ratings of social anxiety and speaking behaviors did not demonstrate a replicated intervention effect; however, Tau-U effect sizes and Reliable Change Index (RCI) calculations demonstrated significant individual improvements in social anxiety and speaking behaviors over time on several measures. Three children (60%) no longer met diagnostic criteria for SM following treatment. All caregivers rated IBTSM as acceptable, with specific endorsements of acceptability in the areas of time required and treatment quality.

Long-term outcomes of selective mutism: a systematic literature review.

BACKGROUND: Selective mutism (SM) is a childhood onset anxiety disorder, and the main symptom is not speaking in certain social situations. Knowledge about the duration and long-term outcomes of SM have been lacking and the aim of this systematic literature review was to address this gap in the literature. We investigated how long SM symptoms persisted as well as other psychiatric outcomes associated with SM in later life. METHODS: The PubMed, PsycInfo, Web of Science, Cochrane Library and Embase databases were initially searched from inception to 11 September 2023. Studies were included if they were published in English and had followed up subjects with clinically diagnosed SM for at least two years. The review followed the Preferred Reporting Items of Systematic Reviews and Meta-analyses guidelines and the protocol was registered with the Open Science Framework. The papers were assessed using the Quality Assessment with Diverse Studies tool. RESULTS: This review screened 2,432 papers and assessed 18 studies. Seven case series studies were excluded from discussion because of the low number of subjects and the fact that their findings could not be generalized to wider populations. In the end, nine clinical cohorts and two case control studies were reviewed. These provided a total of 292 subjects and the sample sizes ranged from 11-49. The overall quality of the studies was moderate. The review found that 190 of the 243 subjects in the studies that reported recovery rates showed moderate or total improvement from SM during follow up. Other anxiety disorders were the most common psychiatric disorders later in life, although these results should be interpreted with caution. Older age at baseline and parental psychopathology might predict greater impairment, but further studies are needed to confirm these results. CONCLUSIONS: Most subjects with SM recovered from this disorder during adolescence, but anxiety disorders were common in later life. Early detection and treatment are needed to prevent symptoms from persisting and other psychiatric disorders from developing.

A systematic review and meta-analysis of nonpharmacological interventions for children and adolescents with selective mutism.

Background: Selective mutism (SM) is an anxiety disorder that often starts in early years with serious and lasting consequences. Nonpharmacological interventions are commonly seen as the preferred first treatment. This systematic review identifies outcome measures used and outcomes achieved for nonpharmacological interventions for children and adolescents with SM. Methods: Systematic searches were conducted using 13 electronic databases and hand searches, including peer-reviewed and grey literature since 1992. Results: Twenty-five studies were identified. While specific measures varied, all studies reported an outcome measure for speaking behaviour and 18 used a measure of anxiety. Few studies reported measures of SM remission (k = 6), well-being (k = 6), academic impact (k = 2), or quality of life (k = 1). Within subject outcomes for nonpharmacological interventions were variable for improvements in speaking behaviours (very small to large positive effects) and reduction in anxiety symptoms (very small negative to large positive effects). Only five randomised controlled trials (RCTs) were included in the meta-analysis. Three studies compared a combined systems/behavioural approach with waitlist controls indicating a significant and large effect (Hedges g = 1.06, p < .0001, 95% CI: 0.57-1.56) on improved speaking behaviour. Two of these RCTs showed a large effect for SM remission favouring the intervention (Risk Ratio = 4.25, p = .1774, 95% CI: 0.52-34.84) but this did not reach statistical significance. Non-significant outcomes for two RCTs with active controls (Hedges g = 0.55, p < .2885, 95% CI: -0.47 to 1.57) showed considerable heterogeneity in approach and outcomes, one with large and one with negligible effects. Conclusion: Despite the considerable impairment caused by SM, there has been little systematic evaluation of non-pharmacological interventions. Although combined systems/behavioural interventions are promising, further systematic evaluations are urgently needed to inform treatment approaches. Cross-study measurement harmonisation is required to promote learning from all studies, including wider clinical and economic outcomes. Clinical Trial Registration: Not applicable.

An Updated Characterization of Childhood Selective Mutism: Exploring Clinical Features, Treatment Utilization, and School Services.

Selective mutism (SM) is a severe but understudied childhood anxiety disorder. Most epidemiological research on SM was conducted decades ago and is limited by small sample sizes. This study analyzes parent-reported clinical data from 230 children with diagnosed and suspected SM to provide current information about the presentation of this disorder. Overall, anxiety and social anxiety symptoms were elevated. Gender ratio, comorbidities and family history of psychopathology were generally aligned with previous research. However, age of onset and diagnosis were both earlier than previously reported, with an average delay of 2 years between onset and diagnosis. The majority of children received therapy and school accommodations for their SM, yet there was large variability in types of interventions. This is the largest survey of children with SM conducted primarily within the US and it constitutes the first systematic inquiry into interventions and accommodations received within clinical and school settings.

Mutismo selectivo: cuando la timidez se hace extrema / Selective mutism: when shyness becomes extreme

El mutismo selectivo es un trastorno poco frecuente y a menudo infradiagnosticado, que puede afectar al rendimiento escolar y repercutir negativamente en su desarrollo. Ocurre antes de los 5 años y está caracterizado por la incapacidad de comunicarse en ámbitos donde el niño no se siente cómodo, como puede ser la escuela; en cambio, en otros lugares, como el domicilio, se comunica y actúa sin problemas. Genera inquietud familiar. Su tratamiento principal es la terapia cognitivo conductual. La combinación de esta terapia con la administración de fármacos se reserva para casos más graves. Se describe a continuación un caso diagnosticado hace 6 meses y en tratamiento desde entonces (AU)

Selective mutism is a less frequent disorder, often underdiagnosed, which negatively affects the child’s development and school performance. This disorder takes place before the age of five. It is characterized with the incapacity to speak in places where the child does not feel comfortable, as school, but at home they speak without problem. In fact, the detection occurs at school, and generates family distress due to their surprise for their child’s attitude. The treatment is based on cognitive-conductive therapy, and just in severe cases pharmacotherapy is needed. A case diagnosed 6 months ago and under treatment since then is described below. (AU)

Symptoms of Selective Mutism in Middle Childhood: Psychopathological and Temperament Correlates in Non-clinical and Clinically Referred 6- to 12-year-old Children.

The purpose of this study was to study psychopathological and temperamental correlates of selective mutism (SM) (symptoms) in a mixed sample of non-clinical (n = 127) and clinically referred (n = 42, of whom 25 displayed the selective non-speaking behavior that is prototypical for SM) 6- to 12-year-old children. Parents completed questionnaires to measure their child's symptom levels of selective mutism, social anxiety, autism spectrum disorder, and the temperament trait of behavioral inhibition. The results first and foremost showed that SM symptoms were clearly linked to social anxiety and an anxiety-prone temperament (behavioral inhibition), but findings also suggested that autism spectrum problems are involved in the selective non-speaking behavior of children. While the latter result should be interpreted with caution given the methodological shortcomings of this study, findings align well with the notion that SM is a heterogeneous psychiatric condition and that clinical assessment and treatment need to take this diversity into account.

Beyond the language barrier: A systematic review of selective mutism in culturally and linguistically diverse children.

Selective mutism is a childhood psychiatric disorder that has been associated with adverse psychological, social and educational outcomes. Although evidence suggests that culturally and linguistically diverse children might be overrepresented among children with selective mutism, a direct examination of how migration or minority status are associated with the development and persistence of the disorder is still scarce. Guided by eco-cultural perspectives of development, the current review aims to provide an overview of selective mutism in culturally and linguistically diverse children. A systematic literature review of selective mutism studies that included a group of culturally and linguistically diverse children yielded eight studies that met our inclusion criteria. Although these studies support the view that bilingualism and minority status might be associated with selective mutism, the role of sociocultural factors in the development and persistence of the disorder remained mostly unexamined. The review concludes with a discussion of potential directions for future research, including examination of the cultural and psychological meanings of silence and talk, socialization goals, gender inequality, and parental acculturation strategies.

Diagnosing selective mutism: a critical review of measures for clinical practice and research.

Selective mutism (SM) is an anxiety disorder (prevalence 1-2%), characterized by the consistent absence of speaking in specific situations (e.g., in school), while adequately speaking in other situations (e.g., at home). SM can have a debilitating impact on the psychosocial and academic functioning in childhood. The use of psychometrically sound and cross-culturally valid instruments is urgently needed.The aim of this paper is to identify and review the available assessment instruments for screening or diagnosing the core SM symptomatology. We conducted a systematic search in 6 databases. We identified 1469 studies from the last decade and investigated the measures having been used in a diagnostic assessment of SM. Studies were included if original data on the assessment or treatment of SM were reported. It was found that 38% of published studies on SM reporting original data did not report the use of any standardized or objective measure to investigate the core symptomatology. The results showed that many different questionnaires, interviews and observational instruments were used, many of these only once. The Selective Mutism Questionnaire (SMQ), Anxiety Disorders Interview Schedule (ADIS) and School Speech Questionnaire (SSQ) were used most often. Psychometric data on these instruments are emerging. Beyond these commonly used instruments, more recent developed instruments, such as the Frankfurt Scale of SM (FSSM) and the Teacher Telephone Interview for SM (TTI-SM), are described, as well as several interesting observational measures. The strengths and weaknesses of the instruments are discussed and recommendations are made for their use in clinical practice and research.

The Integrated Behavior Therapy for Children with Selective Mutism: Findings from an open pilot study in a naturalistic setting.

To test the hypothesis that the Integrated Behavior Therapy for Children with Selective Mutism (IBTSM), administered in a naturalistic setting, is (a) a feasible and acceptable treatment, (b) effective in reducing children's selective mutism (SM) and social anxiety (SA) symptoms, and (c) effective in reducing parents' accommodation behaviors to their children's anxiety. This was an open, uncontrolled trial with assessments at baseline, first session, and post-treatment. The study treated 30 children aged 4-13, using the IBTSM protocol. The diagnosis of SM was established by psychologists using a structured interview. The parents reported levels of SM, SA, and parental accommodation on questionnaires, and the level of children's global functioning was rated by clinicians. Feasibility and acceptability of the IBTSM were assessed using dropout rates, protocol adherence, adverse events, and therapist's acceptability ratings. The IBTSM had acceptable dropout rates, with no adverse events and high acceptability rates. Following IBTSM, children's SM and SA levels, and parents' accommodation, significantly decreased. 75% of children were rated by clinicians as treatment responders. IBTSM is a feasible, acceptable, and efficacious treatment for children with SM, utilized in clinical settings. The results of this open trial must be replicated in randomized controlled studies.

Long-term outcome of selective mutism: factors influencing the feeling of being cured.

Some long-term outcomes for participants with selective mutism (SM) are elevated rates of phobic disorders, particularly social phobia, persistent communicative problems, and reduced self-esteem. However, data on the long-term outcomes of SM are scarce. In this study, by analyzing interpersonal anxiety, communication skills, and self-esteem among those who experienced SM and felt cured (SM-C-group: 30 females, 6 males, mean age 28.0, SD = 7.42, range 19-47 years), those who experienced SM and did not feel cured (SM-NC-group: 37 females, 4 males, mean age 27.4, SD = 7.24, age range 19-50 years), and those who had not experienced SM (Non-SM-group: 30 females, 30 males, mean age 26.4, SD = 7.62, age range: 20-48 years), we examined the long-term outcomes of SM and the factors that influence the feeling of being cured of SM. Results showed that the SM-C-group and SM-NC-groups had significantly higher interpersonal anxiety and significantly lower communication skills than the Non-SM-group. Moreover, the SM-C-group showed significantly lower interpersonal anxiety and significantly higher communication skills than the SM-NC-group. However, while there was no significant difference in self-esteem between the SM-C and SM-NCgroups, there was a significant difference between the SM-NC and Non-SM groups. The SM-C and SM-NC groups did not differ on the retrospective symptom load (SMQ-J), but did on the Current level of difficulty with speaking. The results of the logistic regression analysis predicted that communication skills and self-esteem did not influence the feeling of being cured of SM, but interpersonal anxiety and Current level of difficulty to speak did. Therefore, it is speculated that the intensity of this interpersonal anxiety and whether people with SM still felt difficulty in talking to others may have affected the feeling of being cured from SM.

Clinical characteristics according to sex and symptom severity in children with selective mutism: a four-center study.

INTRODUCTION: Clinical information regarding selective mutism (SM), a persistent and debilitating psychiatric disorder, in children is extremely limited. We aimed to examine sociodemographic characteristics and comorbid psychiatric conditions and identify clinical variables associated with sex and SM severity among children with SM. METHODS: We analyzed the medical records of 49 children who received treatment for SM in four different tertiary hospitals in Turkey between 2016 and 2021. Children's charts were reviewed to examine clinical characteristics, comorbidities, and response to treatment. RESULTS: Thirty-one children were female, and 18 were male (female:male ratio is 1.7:1). Most children (73.5%) with SM displayed onset of SM in 3-6 years. However, most children (57.1%) were diagnosed between the ages of 7-11. The mean time from onset to diagnosis was 1.69 ± 1.37 years. Females displayed a later onset of SM (6.42 ± 2.40 vs. 4.89 ± 0.96; p= 0.013) and higher comorbidity rates (71% vs. 38.9%, p= 0.039) than males. The vast majority of children received two or more psychiatric diagnoses. Children in the severe group had a longer duration of illness, higher rates of psychiatric comorbidity, speech delay, and treatment resistance. CONCLUSION: Our study suggests that SM may have different clinical features according to sex and symptom severity of SM. More information about children with SM is needed to understand the development and maintenance of SM.