Further Outpatient Care

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.^[58]

Social skills problem-solving has shown promise.^[52]

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.^[59]

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)

Further Inpatient Care

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

Inpatient & Outpatient Medications

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.^[60]

Deterrence/Prevention

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.^[61]

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

Patient Education

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.

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