COURTNEY KEETON, PHD

CLINICAL PSYCHOLOGISTASSISTANT PROFESSOR OF PSYCHIATRY

THE JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE

DECEMBER 3 2012

Understanding Selective Mutism

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?

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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 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

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Interpersonal and environmental contexts

Features of CBT

Time-limited Skill-based, problem-specific, goal-oriented

Structured (but flexible)Present and solution-focusedCollaborative Empirically-based (data shows it works!)

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CBT for SM

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CBT for SM

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Targeting Avoidant Behavior

Techniques: Graduated Exposure, Shaping, Stimulus Fading

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Show home video of self talking to doctor

Mouth the names of pictures/colors during game

Whisper counting during “Chutes & Ladders”

Ask questions during “Guess Who”

Read short story aloud

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 feedbackProvide educationSecure 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, PhDThe Johns Hopkins University School of

MedicineDepartment of Psychiatry

Division of Child & Adolescent PsychiatryPhone: 410-614-5174

Email: ckeeton@jhmi.edu

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