Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pediatric Social Phobia and Selective Mutism Follow-up

  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD  more...
 
Updated: May 15, 2014
 

Further Outpatient Care

See the list below:

  • Formal relaxation training can be helpful, and the use of concrete depictions (that relaxation is occurring) may facilitate the process; for example, the use of a biofeedback apparatus including a computer screen that changes color or graphically depicts an increase in the height of a bar graph when a relaxation response occurs (and is measured by objective measurements such as skin conductance, pulse, or blood pressure) may be helpful.
  • Weekly individual cognitive-behavioral therapy and/or group therapy sessions for at least 1 hour per week with appropriate parental involvement are recommended.
  • Support groups for parents of children with selective mutism can be tremendously helpful.[47]
  • Social skills problem-solving has shown promise.[44]
  • Yoga-enhanced cognitive behavioral therapy (Y-CBT) may be a promising new treatment for those with generalized anxiety disorder and possibly for other anxiety disorders such as social anxiety and selective mutism.[48]
  • Additional helpful items may include the following:
    • Supportive educational environment to guard against further additional anxiety or stressors, which worsen the patient's emotional state
    • Close collaboration among school (especially to include the school nurse as part of the team approach), home, and community persons working with the child and family (eg, athletic, music, art, religious personnel) and any therapy providers to reinforce and prevent loss of skills in other areas
    • Medication management (at least initially) by a child psychiatrist or pharmacologically knowledgeable behavioral-developmental pediatrician after appropriate screening, medical examination, and testing results are obtained (weekly or every other week visits until the patient is stabilized and monthly thereafter)
    • Group therapy (more appropriate for older children and adolescents to provide an in vivo experience but may benefit younger children if they are able to participate appropriately in a group)
Next

Further Inpatient Care

See the list below:

  • Further inpatient care is generally unnecessary in patients with selective mutism.
Previous
Next

Inpatient & Outpatient Medications

See the list below:

  • Adjunctive treatment with a low-dose SSRI is indicated if no improvement is observed or if the person's level of functioning deteriorates to the point of not being able to maintain at least 50% level of functioning (ie, missing 50% of days of school or work) after nonresponse to 4-6 weeks of cognitive-behavioral therapy.
  • Avoiding medication with short-half life, such as paroxetine, is recommended to avoid adverse reactions that are more often associated with those medications, such as new onset suicidality, insomnia, and disinhibition.
  • Determining if the individual has a comorbid language or communication disorder is also helpful.[49]
Previous
Next

Deterrence/Prevention

See the list below:

  • Intensive intervention with children or adolescents at high risk for anxiety disorders (eg, those who have a parent with anxiety disorder especially agoraphobia) to prevent development of phobias after traumatic experiences (eg, anesthesia, dog bites, bullying) and encouragement of both the child and family to work through their emotional reactions to stressors soon after the stressor occurs may be needed.[50]
Previous
Next

Complications

Interestingly, children and adolescents with social phobia are less likely to develop a panic attack in response to an infusion of sodium lactate or CO2 than persons with panic disorder.

  • Panic disorder with and without agoraphobia
  • Separation anxiety disorder
  • Generalized anxiety disorder
Previous
Next

Prognosis

See the list below:

  • The prognosis of selective mutism is fair-to-good and depends on the severity of impairment of functioning associated with avoidance of social situations and public speaking and on the presence or absence of secondary gain factors that tend to discourage persons from changing their adaptation to anxiety.
  • Perhaps related to the higher incidence of associated speech and language disorders, children who have social phobia when they are younger than 10 years have a better long-term prognosis. Prognosis is poorer in children older than 12 years who have social phobia than in younger children. Long-term prognosis is perhaps related to the implications of having fewer overall communication skills in social settings or with peers for long-term social skills and language skills development. Also, the baseline problems that provoke the adolescent have the potential to be more long-standing and more serious.
Previous
Next

Patient Education

See the list below:

  • Mild heart rate increases and subjective sensations of a lump in the throat or abdominal discomfort are physiological reactions to stress and are to be expected. These must be differentiated from disabling panic attacks in which simple reassurance does not help. Reactions can decrease as the child or adolescent learns to relax instead of tense up when stressful situations occur.
  • For excellent patient education resources, visit eMedicineHealth's Mental Health Center. Also, see eMedicineHealth's patient education articles Anxiety, Panic Attacks, and Hyperventilation.
Previous
 
Contributor Information and Disclosures
Author

Bettina E Bernstein, DO Distinguished Fellow, American Academy of Child and Adolescent Psychiatry; Distinguished Fellow, American Psychiatric Association; Clinical Assistant Professor of Neurosciences and Psychiatry, Philadelphia College of Osteopathic Medicine; Clinical Affiliate Medical Staff, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Consultant to theVillage, Private Practice; Consultant PMHCC/CBH at Family Court, Philadelphia

Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Chet Johnson, MD Professor of Pediatrics, Associate Director and Developmental-Behavioral Pediatrician, KU Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies; Assistant Dean, Faculty Affairs and Development, University of Kansas School of Medicine

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

References
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. 5th ed. Washington, DC: American Psychiatric Publishing; 2013.

  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.

  3. Manassis K. Silent suffering: understanding and treating children with selective mutism. Expert Rev Neurother. 2009 Feb. 9(2):235-43. [Medline].

  4. Scott S, Beidel DC. Selective mutism: an update and suggestions for future research. Curr Psychiatry Rep. 2011 Aug. 13(4):251-7. [Medline].

  5. Kearney CA, Albano AM. The functional profiles of school refusal behavior. Diagnostic aspects. Behav Modif. 2004 Jan. 28(1):147-61. [Medline].

  6. Sharkey L, Mc Nicholas F. Female monozygotic twins with selective mutism--a case report. J Dev Behav Pediatr. 2006 Apr. 27(2):129-33. [Medline].

  7. Burstein M, Ameli-Grillon L, Merikangas KR. Shyness versus social phobia in US youth. Pediatrics. 2011 Nov. 128(5):917-25. [Medline].

  8. Dirks MA, Weersing VR, Warnick E, Gonzalez A, Alton M, Dauser C. Parent and youth report of youth anxiety: evidence for measurement invariance. J Child Psychol Psychiatry. 2014 Mar. 55(3):284-91. [Medline].

  9. Yeganeh R, Beidel DC, Turner SM. Selective mutism: more than social anxiety?. Depress Anxiety. 2006. 23(3):117-23. [Medline].

  10. Stein MB, Yang BZ, Chavira DA, et al. A common genetic variant in the neurexin superfamily member CNTNAP2 is associated with increased risk for selective mutism and social anxiety-related traits. Biol Psychiatry. 2011 May 1. 69(9):825-31. [Medline].

  11. Lahat A, Lamm C, Chronis-Tuscano A, Pine DS, Henderson HA, Fox NA. Early behavioral inhibition and increased error monitoring predict later social phobia symptoms in childhood. J Am Acad Child Adolesc Psychiatry. 2014 Apr. 53(4):447-55. [Medline].

  12. Guyer AE, Choate VR, Detloff A, Benson B, Nelson EE, Perez-Edgar K. Striatal functional alteration during incentive anticipation in pediatric anxiety disorders. Am J Psychiatry. 2012 Feb. 169(2):205-12. [Medline].

  13. Muchnik C, Ari-Even Roth D, Hildesheimer M, Arie M, Bar-Haim Y, Henkin Y. Abnormalities in auditory efferent activities in children with selective mutism. Audiol Neurootol. 2013. 18(6):353-61. [Medline].

  14. Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010 Oct. 49(10):980-9. [Medline]. [Full Text].

  15. Kopp S, Gillberg C. Selective mutism: a population-based study: a research note. J Child Psychol Psychiatry. 1997 Feb. 38(2):257-62. [Medline].

  16. Bergman RL, Piacentini J, McCracken JT. Prevalence and description of selective mutism in a school-based sample. J Am Acad Child Adolesc Psychiatry. 2002 Aug. 41(8):938-46. [Medline].

  17. Cunningham CE, McHolm AE, Boyle MH. Social phobia, anxiety, oppositional behavior, social skills, and self-concept in children with specific selective mutism, generalized selective mutism, and community controls. Eur Child Adolesc Psychiatry. 2006 Aug. 15(5):245-55. [Medline].

  18. Siegel RS, Dickstein DP. Anxiety in adolescents: Update on its diagnosis and treatment for primary care providers. Adolesc Health Med Ther. 2012. 3:1-16. [Medline].

  19. Steinhausen HC, Wachter M, Laimböck K, Metzke CW. A long-term outcome study of selective mutism in childhood. J Child Psychol Psychiatry. 2006 Jul. 47(7):751-6. [Medline].

  20. Remschmidt H, Poller M, Herpertz-Dahlmann B, Hennighausen K, Gutenbrunner C. A follow-up study of 45 patients with elective mutism. Eur Arch Psychiatry Clin Neurosci. 2001 Dec. 251(6):284-96. [Medline].

  21. Dammann O, Naples M, Bednarek F, Shah B, Kuban KC, O''Shea TM, et al. SNAP-II and SNAPPE-II and the Risk of Structural and Functional Brain Disorders in Extremely Low Gestational Age Newborns: The ELGAN Study. Neonatology. 2009 Aug 11. 97(2):71-82. [Medline]. [Full Text].

  22. Politi K, Kivity S, Goldberg-Stern H, Halevi A, Shuper A. Selective mutism and abnormal electroencephalography (EEG) tracings. J Child Neurol. 2011 Nov. 26(11):1377-82. [Medline].

  23. Viana AG, Beidel DC, Rabian B. Selective mutism: a review and integration of the last 15 years. Clin Psychol Rev. 2009 Feb. 29(1):57-67. [Medline].

  24. Scharfstein L, Alfano C, Beidel D, Wong N. Children with generalized anxiety disorder do not have peer problems, just fewer friends. Child Psychiatry Hum Dev. 2011 Dec. 42(6):712-23. [Medline]. [Full Text].

  25. Williford A, Boulton A, Noland B, Little TD, Kärnä A, Salmivalli C. Effects of the KiVa anti-bullying program on adolescents' depression, anxiety, and perception of peers. J Abnorm Child Psychol. 2012 Feb. 40(2):289-300. [Medline].

  26. Wong P. Selective mutism: a review of etiology, comorbidities, and treatment. Psychiatry (Edgmont). 2010 Mar. 7(3):23-31. [Medline]. [Full Text].

  27. Carbone D, Schmidt LA, Cunningham CC, McHolm AE, Edison S, St Pierre J, et al. Behavioral and socio-emotional functioning in children with selective mutism: a comparison with anxious and typically developing children across multiple informants. J Abnorm Child Psychol. 2010 Nov. 38(8):1057-67. [Medline].

  28. Guntheroth W. Link among mitral valve prolapse, anxiety disorders, and inheritance. Am J Cardiol. 2007 May 1. 99(9):1350. [Medline].

  29. Maeda F, Nathan JH. Understanding taijin kyofusho through its treatment, Morita therapy. J Psychosom Res. 1999 Jun. 46(6):525-30. [Medline].

  30. Needleman H. Lead poisoning. Annu Rev Med. 2004. 55:209-22. [Medline].

  31. Castillo EM, Butler IJ, Baumgartner JE, Passaro A, Papanicolaou AC. When epilepsy interferes with word comprehension: findings in Landau-Kleffner syndrome. J Child Neurol. 2008 Jan. 23(1):97-101. [Medline].

  32. Kennard BD, Silva SG, Mayes TL, Rohde P, Hughes JL, Vitiello B, et al. Assessment of safety and long-term outcomes of initial treatment with placebo in TADS. Am J Psychiatry. 2009 Mar. 166(3):337-44. [Medline].

  33. Brent DA, Emslie GJ, Clarke GN, Asarnow J, Spirito A, Ritz L, et al. Predictors of spontaneous and systematically assessed suicidal adverse events in the treatment of SSRI-resistant depression in adolescents (TORDIA) study. Am J Psychiatry. 2009 Apr. 166(4):418-26. [Medline].

  34. Goldberg EM, Titulaer M, de Blank PM, Sievert A, Ryan N. Anti-N-methyl-D-aspartate receptor-mediated encephalitis in infants and toddlers: case report and review of the literature. Pediatr Neurol. 2014 Feb. 50(2):181-4. [Medline].

  35. Schum RL. Language screening in the pediatric office setting. Pediatr Clin North Am. 2007 Jun. 54(3):425-36, v. [Medline].

  36. Letamendi AM, Chavira DA, Hitchcock CA, Roesch SC, Shipon-Blum E, Stein MB. Selective Mutism Questionnaire: Measurement Structure and Validity. J Am Acad Child Adolesc Psychiatry. 2008 Aug 8. [Medline].

  37. March JS, Parker JD, Sullivan K, et al. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1997 Apr. 36(4):554-65. [Medline].

  38. Kaufman J, Birmaher B, Brent DA, et al. K-SADS-PL. J Am Acad Child Adolesc Psychiatry. 2000 Oct. 39(10):1208. [Medline].

  39. Birmaher B, Khetarpal S, Brent D, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry. 1997 Apr. 36(4):545-53. [Medline].

  40. Scaini S, Battaglia M, Beidel DC, Ogliari A. A meta-analysis of the cross-cultural psychometric properties of the Social Phobia and Anxiety Inventory for Children (SPAI-C). J Anxiety Disord. 2012 Jan. 26(1):182-8. [Medline].

  41. Ponzurick JM. Selective mutism: a team approach to assessment and treatment in the school setting. J Sch Nurs. 2012 Feb. 28(1):31-7. [Medline].

  42. Lang R, Regester A, Mulloy A, Rispoli M, Botout A. Behavioral intervention to treat selective mutism across multiple social situations and community settings. J Appl Behav Anal. 2011 Fall. 44(3):623-8. [Medline]. [Full Text].

  43. Kearney CA. School absenteeism and school refusal behavior in youth: a contemporary review. Clin Psychol Rev. 2008 Mar. 28(3):451-71. [Medline].

  44. O'Reilly M, McNally D, Sigafoos J, Lancioni GE, Green V, Edrisinha C, et al. Examination of a social problem-solving intervention to treat selective mutism. Behav Modif. 2008 Mar. 32(2):182-95. [Medline].

  45. Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007 Apr 18. 297(15):1683-96. [Medline].

  46. Cooper WO, Callahan ST, Shintani A, Fuchs DC, Shelton RC, Dudley JA. Antidepressants and suicide attempts in children. Pediatrics. 2014 Feb. 133(2):204-10. [Medline].

  47. Sharkey L, Mc Nicholas F, Barry E, Begley M, Ahern S. Group therapy for selective mutism - a parents' and children's treatment group. J Behav Ther Exp Psychiatry. 2008 Dec. 39(4):538-45. [Medline].

  48. Khalsa MK, Greiner-Ferris JM, Hofmann SG, Khalsa SB. Yoga-Enhanced Cognitive Behavioural Therapy (Y-CBT) for Anxiety Management: A Pilot Study. Clin Psychol Psychother. 2014 May 7. [Medline].

  49. Manassis K, Tannock R. Comparing interventions for selective mutism: a pilot study. Can J Psychiatry. 2008 Oct. 53(10):700-3. [Medline].

  50. Anyfantakis D, Botzakis E, Mplevrakis E, Symvoulakis EK, Arbiros I. Selective mutism due to a dog bite trauma in a 4-year-old girl: a case report. J Med Case Rep. 2009 Nov 3. 3:100. [Medline]. [Full Text].

  51. Evans CE, Sebastian J. Serotonin syndrome. Emerg Med J. 2007 Apr. 24(4):e20. [Medline]. [Full Text].

  52. Wichman CL, Moore KM, Lang TR, St Sauver JL, Heise RH Jr, Watson WJ. Congenital heart disease associated with selective serotonin reuptake inhibitor use during pregnancy. Mayo Clin Proc. 2009. 84(1):23-7. [Medline]. [Full Text].

  53. Chambers CD, Hernandez-Diaz S, Van Marter LJ, Werler MM, Louik C, Jones KL, et al. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med. 2006 Feb 9. 354(6):579-87. [Medline].

  54. Bond GR, Garro AC, Gilbert DL. Dyskinesias associated with atomoxetine in combination with other psychoactive drugs. Clin Toxicol (Phila). 2007. 45(2):182-5. [Medline].

  55. Chavira DA, Shipon-Blum E, Hitchcock C, Cohan S, Stein MB. Selective mutism and social anxiety disorder: all in the family?. J Am Acad Child Adolesc Psychiatry. 2007 Nov. 46(11):1464-72. [Medline].

  56. Cheung AH, Emslie GJ, Mayes TL. The use of antidepressants to treat depression in children and adolescents. CMAJ. 2006 Jan 17. 174(2):193-200. [Medline].

  57. Cohan SL, Chavira DA, Shipon-Blum E, Hitchcock C, Roesch SC, Stein MB. Refining the classification of children with selective mutism: a latent profile analysis. J Clin Child Adolesc Psychol. 2008 Oct. 37(4):770-84. [Medline].

  58. Hayward C, Killen JD, Kraemer HC, Taylor CB. Linking self-reported childhood behavioral inhibition to adolescent social phobia. J Am Acad Child Adolesc Psychiatry. 1998 Dec. 37(12):1308-16. [Medline].

  59. Hudson JL, Comer JS, Kendall PC. Parental responses to positive and negative emotions in anxious and nonanxious children. J Clin Child Adolesc Psychol. 2008 Apr. 37(2):303-13. [Medline].

  60. Huska MT, Catalano G, Catalano MC. Serotonin syndrome associated with the use of escitalopram. CNS Spectr. 2007 Apr. 12(4):270-4. [Medline].

  61. Kearney CA, Vecchio JL. When a child won't speak. J Fam Pract. 2007 Nov. 56(11):917-21. [Medline].

  62. Kennard B, Silva S, Tonev S, Rohde P, Hughes J, Vitiello B, et al. Remission and Recovery in the Treatment for Adolescents With Depression Study (TADS): Acute and Long-Term Outcomes. J Am Acad Child Adolesc Psychiatry. 2009 Jan 2. [Medline].

  63. Klein DF. The Flawed Basis for FDA Post-Marketing Safety Decisions: The Example of Anti-Depressantsand Children. Neuropsychopharmacology. 2005 Dec 14. [Medline].

  64. Looper KJ. Potential medical and surgical complications of serotonergic antidepressant medications. Psychosomatics. 2007 Jan-Feb. 48(1):1-9. [Medline].

  65. McInnes A, Manassis K. When silence is not golden: an integrated approach to selective mutism. Semin Speech Lang. 2005 Aug. 26(3):201-10. [Medline].

  66. [Guideline] Nelson LS, Erdman AR, Booze LL, et al. Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007. 45(4):315-32. [Medline].

  67. Packer S, Berman SA. Serotonin syndrome precipitated by the monoamine oxidase inhibitor linezolid. Am J Psychiatry. 2007 Feb. 164(2):346-7. [Medline].

  68. Reinblatt SP, Riddle MA. The pharmacological management of childhood anxiety disorders: a review. Psychopharmacology (Berl). 2007 Mar. 191(1):67-86. [Medline].

  69. Reinblatt SP, Walkup JT. Psychopharmacologic treatment of pediatric anxiety disorders. Child Adolesc Psychiatr Clin N Am. 2005 Oct. 14(4):877-908, x. [Medline].

  70. Shapiro RE, Tepper SJ. The serotonin syndrome, triptans, and the potential for drug-drug interactions. Headache. 2007 Feb. 47(2):266-9. [Medline].

  71. Sharkey L, McNicholas F. More than 100 years of silence', elective mutism: a review of the literature. Eur Child Adolesc Psychiatry. 2008 Aug. 17(5):255-63. [Medline].

  72. Sharp WG, Sherman C, Gross AM. Selective mutism and anxiety: a review of the current conceptualization of the disorder. J Anxiety Disord. 2007. 21(4):568-79. [Medline].

  73. Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006. 163:41-47. [Medline].

  74. Smith EG. Association between antidepressant half-life and the risk of suicidal ideation or behavior among children and adolescents: confirmatory analysis and research implications. J Affect Disord. 2009 Apr. 114(1-3):143-8. [Medline].

  75. Varley CK. Treating depression in children and adolescents: what options now?. CNS Drugs. 2006. 20(1):1-13. [Medline].

  76. Vitiello B. Truly independent research? Treatment for Adolescents with Depression Study (TADS). BMJ. 2008 Oct 13. 337:a2070. [Medline].

  77. Wagner KD. Pharmacotherapy for major depression in children and adolescents. Prog Neuropsychopharmacol Biol Psychiatry. 2005 Jun. 29(5):819-26. [Medline].

Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.