Pediatric Social Phobia and Selective Mutism 

Updated: Apr 14, 2020
Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD 

Overview

Background

Selective mutism is defined by the Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition (DSM-5) as “an anxiety disorder, given that a large majority of children with selective mutism are anxious.”[1]

Selective mutism is a disorder in which an individual is not able to speak aloud in specific situations when there is an expectation of conversational speech.[1] Communicative language is generally intact in such individuals, although selective mutism can coexist with language and communication disorders.

Selective mutism can be accompanied by other anxiety disorders such as separation anxiety disorder, social anxiety disorder (formerly called social phobia), agoraphobia, and panic disorder, as well as by shyness and anxiety; however, it can also exist without other anxiety-related disorders.[2]

Selective mutism generally occurs by age 5 years; however, usually it is not diagnosed until the child starts school. In some cases, adolescents and adults continue to experience an inability to speak in public. This inability is generally most disabling at school, as the child cannot be assertive and speak when called on by teachers. In adults, functional impairment occurs when public speaking or lecturing is required in one's vocation. Often, the child with selective mutism designates a friend or close family member to serve as an interpreter of communication and whispers into that person's ear, so that communication occurs with the designated person as intermediary.

Often, selective mutism can coexist with social phobia, also known as social anxiety, and is defined by marked and persistent fear of social or performance situations in which embarrassment may occur; exposure to the social or performance situation almost always causes an anxiety reaction such as a situationally bound or situationally predisposed panic attack.

Selective mutism can also be the precursor to agoraphobia and/or panic disorder. Agoraphobia is a specific phobia in which the individual fears being in crowded places. People with agoraphobia often become homebound. Panic disorder can result in significant disability and iatrogenically induced illness, especially in situations when invasive medical testing is done, because the severity of symptoms such as chest pain and palpitations and medical testing can intensify the severity of the panic symptoms.

The anxiety reaction is not due to psychosis; individuals are able to recognize their fears as excessive and unreasonable. However, the ability to fully comprehend that the reaction is out of proportion to the precipitant may be less complete in children and may depend on their cognitive-developmental level of functioning due to deficits in emotional regulation. Recent studies have looked at physiological measures reflecting the severity of anxiety. Children with selective mutism were compared with children with social phobia in a study of 35 children (average age, 8 y). Those with social phobia and selective mutism had chronically higher levels of arousal as reflected by respiratory sinus arrhythmia and skin conductance levels. This may help explain why children with selective mutism may appear to others to not be overtly anxious; their silence may serve to decrease outward signs of anxiety observable by others.[3]

Studies that use physiological measures to objectively measure the severity of anxiety have shown that children with selective mutism and social anxiety as compared with children with social phobia alone have chronically higher levels of arousal (more intense anxiety) as reflected in the presence of respiratory sinus arrhythmia and skin conductance levels. Children with selective mutism may appear to others to not be overtly anxious, especially because of their silence, as their anxiety is not directly observable by others.[3]

Selective mutism significantly impairs the individual's level of functioning, as the individual is unable to complete required educational, social, and family tasks, and the emotional distress engendered in situations requiring the person to speak out loud can result in school refusal.[4]

Selective mutism is a disorder that first occurs in childhood and can continue into adolescence and adulthood. In adults with this disorder, functional impairment occurs when public speaking or lecturing are required in one's vocation. Severe social anxiety may not be evident, as the person may actually function in a relaxed manner when using nonverbal (ie, gestures, signing) communication styles.[5]

Shyness does not necessarily persist in adolescents with social anxiety disorder. A study by Burstein et al found that almost 50% of a group rated themselves shy; however, only 12% of adolescents who identified themselves as shy actually met criteria for lifetime incidence of social anxiety disorder as measured by the World Health Organization Composite International Diagnostic Interview 3.0, and 5.2% of adolescents who did not identify as having shyness had social phobia.[6]

There is significant comorbidity of social phobia with anxiety disorders, major depressive disorder, and drug use disorders, without regard to the presence or absence of shyness. Adolescents with shyness were more likely to report agoraphobia compared with the no-shyness group. Adolescents with social phobia versus adolescents with shyness had greater impairment in the areas of school/work, family relationships, and social life; however, they were no more likely to obtain professional treatment. Eighty percent of adolescents with social phobia failed to seek or to obtain professional treatment for their anxiety, and rates of prescribed medication use were systematically low across groups: 2.3% of adolescents with social phobia and 0.9% of adolescents with shyness used paroxetine.

Adolescent gender did not have a significant effect on the prevalence of social phobia. However, culture can cause parents to underreport anxiety; a clinically referred sample of 408 parent-youth dyads of African American adolescents versus Latino and white adolescents that used the Screen for Child Anxiety Related Emotional Disorders (SCARED) found that parents tended to significantly underreport anxiety symptoms.[7]

Pathophysiology

Serotonin pathways may be involved in the mediation of the anxious and obsessive qualities of selective mutism. This theory is reinforced by animal models of phobic behavior and by response to commonly prescribed medications such as selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, sertraline, or older heterocyclic-type antidepressants (eg, clomipramine [Anafranil]).[8]

Continued studies are needed to help to determine the genetics of anxiety-related negative valence system (NVS) traits (fear/threat, potential harm/anxiety, sustained threat/loss, frustrative non reward) as it continues to be challenging to identify candidate gene and Genome Wide Association Studies (GWAS).[9]

A study of 106 children with selective mutism also included 1028 young adults who completed measures of social interactional anxiety and 920 young adults with childhood behavioral inhibition.[10] The study found a nominal significance (P = .018) for association of selective mutism with rs2710102, which, with rs6944808, was part of a common haplotype associated with selective mutism (permutation P = .022). Adjusting for sex and ancestral proportion, each copy of the rs2710102*, a risk allele in the young adults, was associated with increased odds of being more than 1 standard deviation above the mean on the Social Interactional Anxiety Scale (odds ratio = 1.33; P = .015) and Retrospective Self-Report of Inhibition (odds ratio = 1.40; P = .010).

This study is very encouraging that future genome-wide association studies might reflect an association of early onset variant of social anxiety disorder and selective mutism to a susceptibility gene, contactin-associated protein-like 2 (CNTNAP2), which has been found in other studies in relation to autism spectrum disorders. rs2710102 is a possible nonrisk allele for autism spectrum disorders and specific language impairment and may also relate to handedness.[11]

Behavioral inhibition is an early childhood temperament characterized by fearful responses to novelty and avoidance of social interactions. During adolescence, a subset of children with stable childhood behavioral inhibition develop social anxiety disorder and concurrently exhibit increased error monitoring. Increased error monitoring in 7-year-olds who were characterized regarding behavioral inhibition at age 24 and 36 months prospectively predicted risk for symptoms of social phobia at age 9 years in a study of 291 children. Those high in behavioral inhibition had increased error monitoring at age 7 years, as indexed by larger (ie, more negative) error-related negativity amplitudes. In addition, early behavioral inhibition was related to later childhood social phobia symptoms at age 9 years among children with a large difference in amplitude between error-related negativity and correct-response negativity at age 7 years.

Heightened error monitoring predicts risk for later social phobia symptoms in children with high behavioral inhibition. Research assessing response monitoring in children with behavioral inhibition may refine our understanding of the mechanisms underlying risk for later anxiety disorders and the possible need for prevention efforts.[12]

Adolescents with early-life behavioral inhibition, similar to adolescents with social phobia, did not have striatal sensitivity to valence or self-reported affective sensitivity to incentive magnitude, which supported specificity in features of generalized anxiety disorder relative to social phobia or behavioral inhibition. Distinct striatal subregion responses showed a more generalized pattern of striatal response in adolescents with social phobia when compared with their healthy peers, and this pattern emerged across the caudate, putamen, and nucleus accumbens. Widespread magnitude-related incentive activations had underlied psychological states common to behavioral inhibition and social phobia, such as performance monitoring or sensitivity to feedback and caudate hyperactivation in social phobia, and behavioral inhibition suggested anomalies in goal-based processes, which were more strongly modulated in the caudate rather than in the putamen or nucleus accumbens.[13]

Two efferent feedback pathways to the auditory periphery may play a role in monitoring self-vocalization: the middle-ear acoustic reflex (MEAR) and the medial olivocochlear bundle (MOCB) reflex. In selective mutism compared with a group of normally developing control children, a significantly higher proportion of selective mutism children had abnormal MEAR and MOCB function (58.6% and 38%, respectively) compared with controls (9.7% and 8%, respectively). The overall prevalence of abnormal MEAR and/or MOCB function was significantly higher in the selective mutism group (71%) compared with controls (16%).[14]

Epidemiology

Frequency

The average age of onset of all anxiety disorders is 11 years, which reflects that anxiety disorders are common in children and adolescents.

In the National Comorbidity Survey-Replication-Adolescent Supplement, an epidemiologic sample of 10,123 adolescents in the United States, prevalence estimates for the different anxiety disorders were as follows: generalized anxiety disorder, 2.2%; social phobia, 9.1%; specific phobia, 19.3%; panic disorder, 2.3%; and separation anxiety, 7.6%.[15]

Social phobia is the third most common mental health disorder after depression.[16] Bergman et al (2002) reported that the prevalence rate of selective mutism was 0.71% but ranged from 0.08% to 1.9% depending on the population studied.[17]

Selective mutism is seen in fewer than 1% of children observed in mental health settings and is reported about 2–2.5 times more often in females than in males. The onset of selective mutism usually occurs during the preschool years, however often it is not diagnosed until the child attends school. The diagnosis of selctive mutism often can be misdiagnosed as oppositional defiant disorder because of the significant features of oppositionality and defiance that frequently accompany the child's refusal to speak especially in the school setting. With increased chronological age, a significant percentage of children "outgrow" the selective mutism however some children continue to have difficulty with public speaking and exhibit sparse language production compared with their age mates.[18]

Mortality/Morbidity

Generally, mortality does not result directly from selective mutism, except in cases of associated major depression resulting in suicide or reaction to medication treatment (sudden cardiac death with imipramine or clonidine) or adverse reaction such as newly onset suicidality following therapy with SSRIs or other antidepressants. A high morbidity rate is observed, with many missed school or workdays; the child often develops associated school refusal because of the anxiety associated with being asked to speak in class.[18]

There is a potential risk of iatrogenically induced illness in situations in which there is severe physical symptoms of panic disorder due to the likelihood that invasive medical testing might be performed if symptoms include palpitations or chest pain.[19]

Sex

Selective mutism is diagnosed more often in females than in males, with a female-to-male ratio of about 2-2.5:1.[17]

Age

Onset of selective mutism may occur as early as school age but generally occurs by mid adolescence following a childhood history of social inhibition or excessive shyness.[2]

The onset of selective mutism is often abrupt, occurring after a stressor or humiliating social experience and typically occurs when a child first attends school (either kindergarten or preschool). Over time, anxiety levels tend to increase as children do not "grow out of" selective mutism.[20] Selective mutism persists as low self-confidence, shyness, and discomfort in social situations, often persisting into adulthood when speaking in public is required.[21]

Prognosis

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.

Prognosis is also considered worse if there is a family history of selective mutism.[22]

Patient Education

Parental involvement including appropriate interventions as early as in the first session can increase effectiveness of the treatment of selective mutism as well as the provision of school-based delivery of CBT.  A five-year follow-up study of 30 youth found that 21 were in remission and five years later 21% of the group continued to have persistent symptoms implying chronicity of this disorder.[22]

 

Presentation

History

Careful attention to a history of caffeine overuse can be helpful, as caffeinism commonly mimics symptoms of anxiety. The family history often includes anxiety disorders (both social phobia and selective mutism). Selective mutism may frequently coexist with other speech and language disorders (eg, expressive-receptive language disorder, expressive writing disorder). Social or performance situations (eg, public speaking, performing in a school play) are typically avoided (or barely endured) by persons with social phobia and those with selective mutism.

DSM-5 diagnostic criteria for persons younger than 18 years state that, to be considered selective mutism, symptoms must persist for at least 6 months, must not be due to the direct physiological effects of a substance (eg, caffeine) or to a general medical condition, and must not be better accounted for by another mental health disorder (eg, depression, acute psychosis).[1]

The Bayley-Infant Neurodevelopmental Screener is commonly used in children younger than 3 years who generally have low birth weight and suspected intellectual disability.[23]

Physical

Children with selective mutism may have a possible higher risk of electroencephalographic abnormalities that may reflect an eventual diagnosis of benign epilepsy of childhood or a more complex organic brain disorder.[24]

Causes

The etiology of selective mutism is multifactorial. Some children develop selective mutism after a stressor such as illness, separation from their caregiver, or other traumatic experiences such as abuse or neglect and bullying can especially contribute risk and also occur related to the lack of a large supportive peer group. This is because youth with selective mutism are not as likely as "normal" unaffected peers to be protected by peer bystanders from being targeted and victimized by bullying.[25, 26]

Programs that are effective (such as Olweus, KiVa) to prevent bullying are especially important for youth with social anxiety and selective mutism. A study using structural equation modeling and random assignment to either intervention or control condition of 7,741 students from 78 schools looked at the effects of the KiVa antibullying program on students' anxiety, depression, and perception of peers in grades 4-6; reductions in peer-reported victimization may have predicted changes in anxiety and depression symptoms.[27]

Other children with selective mutism have an underlying language delay or disorder (most often expressive language disorder) or severe social anxiety and shyness. Some children report fearing the sound of their own voice. Adverse peer interactions frequently include peer social rejection and scapegoating directly related to the selective mutism.[28, 29]

Several genetic factors are being studied. (See Pathophysiology)

Instances of family members "speaking for" the children with selective mutism serve as positive reinforcement for not speaking, and this may also be self-reinforcing, as the child does not have to separate from them.[29]

  • Children with selective mutism are at higher risk for developing other developmental disorders, such as enuresis, encopresis, and abnormal EEG findings (because of immaturity), as well as developmental speech and language disorders. These disorders are also associated with increased incidence among first- or second-degree relatives.[29, 30]

  • Mitral valve prolapse has not been associated with anxiety disorders in general and social (anxiety) phobia specifically.[31]

  • A cross-cultural perspective is essential. In Japan and Korea, what persons living in the West classify as social phobia may manifest as persistent and excessive fears of offending others in social situations instead of embarrassment (ie, taijin kyofusho), including fears that blushing, eye-to-eye contact, or one's body odor could be offensive to others.[32]

 

DDx

Diagnostic Considerations

Other diagnoses to consider include the following:

  • Difficulties with language acquisition (English as a second language)

  • Expressive-receptive language disorder

  • Mental retardation

  • Childhood-acquired aphasia

  • Apraxia due to head trauma

  • Cerebral palsy

  • Panic disorder with or without agoraphobia

  • Mood disorder

  • Substance-related disorder

  • Kleffner-Landau syndrome

  • AntiNMDA receptor encephalitis

Differential Diagnoses

 

Workup

Laboratory Studies

If selective mutism is indicated based on history and physical examination, perform the following tests to rule out other medical problems or to assess baseline function prior to starting medication:

  • CBC count - To exclude anemia or another blood dyscrasia as a preexisting condition or contraindication to the use of psychotropic medication

  • Triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) - To exclude hypothyroidism, which may also accompany depression as a cause of a hypoglossal nerve motor problem (eg, glossal articulation difficulty causing language disfluency)

  • Metabolic screening for sodium, BUN, and creatinine - To exclude renal impairment or renal failure as a contraindication to medication treatment; especially important because of the potential side effects of hyponatremia resulting from treatment with SSRIs

  • Serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase - To exclude liver problems as a contraindication to medication treatment (prior to initiation).

  • Lead level - To exclude language delay (as evidenced by cognitive delay) due to elevated lead levels[33]

Rule out Landau-Kleffner syndrome (LKS), especially in a child with seizure disorder with a history of loss of previously acquired skills such as toileting, social interaction, or language.[34]

The patient should be carefully monitored when doses are changed or new medications started. When SSRIs or serotonin and norepinephrine reuptake inhibitors [SNRIs]) are started, monitored should occur weekly at first, then every other week, then monthly to detect newly onset suicidality or agitation. Monitor for adverse reactions when psychotropics or antidepressants are prescribed.[35, 36]

If the patient’s condition deteriorates and there are abnormalities in the neurological examination, such as dystonia, gait impairment, seizures, and mutism, then it is important to consider referral to a neurologist to determine the presence or absence of anti-N -methyl-D-aspartate receptor encephalitis—an increasingly well-recognized inflammatory encephalitis in children and adults.[37]

Imaging Studies

See the list below:

  • Brain MRI: This is generally performed if an acute or chronic brain abnormality is suspected as a cause of language delay. For example, in a child with an acute change of mental status or functioning, MRI would be used to rule out a brain tumor, especially of the fourth ventricle, which rarely manifests as this type of change.

  • EEG: This can be helpful to diagnose Landau-Kleffner syndrome, a potential cause of language delay or juvenile epilepsy.[34]

Other Tests

See the list below:

  • Language screening - Usually performed by a licensed speech and language pathologist who can also serve as the primary clinician if the child has a language disorder[38]

  • Screening physical examination, including hearing testing and a screening neurologic examination - To exclude tumors or other disorders (eg, aphasia)[38]

  • ECG - To exclude any cardiac contraindication to medication treatment, such as a cardiac conduction abnormality or arrhythmia prior to medication treatment[31]

  • EEG with neurologist consultation - To exclude a neurologic condition, including seizures, and to rule out Landau-Kleffner syndrome, especially if a language delay and seizures are suspected[34]

  • Structured or semistructured interview - To help to determine past or present history of self-harm or potentially suicidal behavior in the patient or a family history of suicidality

  • Psychometric screening tests - To confirm a diagnosis of selective mutism, to judge treatment responsiveness, and to help assess level of acuity and severity

    • Instruments such as those below are primarily used in research studies but can be helpful for confirming a clinical diagnosis, for monitoring the response to treatment, and for assessing the level of acuity and severity. The following specific anxiety inventories are useful in following response to treatment that may be slow and initially subtle:

      • The Selective Mutism Questionnaire (SMQ) is a 17-item questionnaire that is helpful in assessing severity.[39]

      • The Multidimensional Anxiety Scale for Children (MASC) is a specific screening test for anxiety and related disorders that was developed by March and colleagues at Duke University.[40]

      • The Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) is a semistructured diagnostic interview for children aged 6-17 years. It was developed as a screening instrument for use by clinically sophisticated (ie, mental health) interviewers. The K-SADS inventory was originally developed by Orvaschel, Puig-Antich, and Chambers to screen for affective disorders, anxiety disorders, schizophrenia, and schizophreniform disorders. K-SADS has been revised and updated by Kaufman, Birmaher, and Brent at Western Pennsylvania Psychiatric Institute.[41]

      • Screen for Child Anxiety Related Emotional Disorders (SCARED) is a specific screening test for anxiety and phobic disorders. It was developed by Birmaher et al at Western Pennsylvania Psychiatric Institute and is helpful in confirming the clinical diagnosis of anxiety disorders.[42]

      • The Social Phobia and Anxiety Inventory for Children (SPAI-C) assessment, an empirically derived self-report instrument to assess DSM-IV social phobia in childhood and adolescence, has good psychometric properties and has been replicated across different cultures.[43]

  • The Connors' Parent-Teacher Questionnaire was designed as a checklist. It is generally more accurate in providing corroborating evidence for externalizing disorders such as conduct problems or attention deficit/hyperactivity disorder (ADHD). The questionnaire may be used when an anxiety disorder and an externalizing disorder such as ADHD or conduct disorder are comorbid. The instrument does not, however, clarify the diagnosis when an anxious child is being oppositional in the face of being forced into new situations.

  • Projective testing (eg, Rorschach, Children's Apperception Test) - Should be performed only by a licensed clinical psychologist; not to be substituted for a careful clinical interview by a skilled clinician; especially helpful to rule out personality disorders or psychosis (testing for loss of reality)[38]

 

Treatment

Approach Considerations

Although behavior therapy, including CBT, integrated behavior therapy, and S-CAT, are standard treatments for selective mutism[22] , other approaches to treatment include music therapy, play therapy,[44] parent-child interaction therapy, short-term psychoanalytic therapy, hypnosis, and a two-session behavior therapy approach using mobile apps.[45]

S-CAT principles include a three-session CBT intervention for the child and parentat home and then extendeds as school-based CBT, as children with selective mutism tend to be most symptomatic in the school environment. Defocused communication as a general treatment principle included six central components:

  1. To sit beside rather than opposite the child;
  2. To create joint attention using an activity the child enjoys rather than focusing on the child;
  3. To ‘think aloud’ rather than asking the child direct questions;
  4. To give the child enough time to respond rather than talking for the child;
  5. To continue the dialog even though the child does not respond verbally; and
  6. Try to receive a verbal answer in a neutral way rather than praising the child. [46]

Technological advances that are promising include the use of mobile apps to assist successive approximation of speech earlier in treatment as a pilot study was able to show improvement after two sessions.[45]

Medical Care

Prevention of complications of selective mutism (eg, school phobia, academic failure due to poor attendance) can be achieved by reinforcement by family, school, and physician of how important attending school is despite the child's desire to stay home and to avoid social events in order to reduce anxiety.[47, 48]

SSRIs are effective and superior to placebo, with efficacy rates of at least 65% in the treatment of patients with social phobia and the related disorder, selective mutism especially when used synergistically with cognitive-behavioral therapy (CBT). The doses used in both children and adults can be higher than those used for affective disorders.[49, 50]

Cognitive-behavioral therapy may be extremely helpful to improve the level of the child's autonomous functioning and should be performed by a clinician experienced in such therapy (eg, psychologist, psychiatrist, behavioral/developmental pediatrician). Cognitive approaches to both social phobia and selective mutism may be grouped into the several following types:

  • Contingency combined with stimulus fading: The desired behavior (ie, speaking out loud) is elicited with a stimulus or prompt; then, the prompt is gradually faded by decreasing the number of prompts, eventually to zero.

  • Behavior shaping combined with positive reinforcers: The child is rewarded every time she exhibits behavior that is closer and closer to the desired behavior (ie, speaking out loud).[51]

  • Positive reinforcers: Use of positive reinforcers such as a token economy or reward system for perfect attendance at school and special treats, such as a favorite book or movie for attending social events, may be successful.[52]

  • Aversive interventions: Forcing the child to speak out loud generally does not encourage the behavior to occur more often.

  • Systematic desensitization: The child or adolescent relearns how not to be upset or anxious when in a social situation. Instead of feeling uncomfortable in the situation, the child connects feelings of calm with the previously anxiety-provoking social situation. Instead of automatically reacting to the anxiety-provoking situation with autonomic nervous system activation, the behavioral response is reconditioned to that of relative autonomic nervous system deactivation.

  • Extinction: The undesired behavior (refusing to speak, hiding, refusing to go to school) is ignored, and the lack of attention to the behavior causes the behavior to cease.[51]

  • Modeling: The child or adolescent learns from a peer or adult therapist how to react in a calmer manner to the stressful situation. Research studies support the efficacy of using audio tapes or videotapes in treating selective mutism.

  • In vitro graded exposure: The child or adolescent imagines the stressful situation starting with the least stressful aspects, learning how to deal with these, and then following up with more stress-provoking aspects. This could include the use of scripted play therapy using real-life stressful situations with targeted responses for learning and incorporation.

  • In vivo exposure: The situation becomes less tension-provoking with repeated graded exposures as the situation becomes less new and more predictable. Careful real-life exposure (from less-threatening to more-threatening) to anxiety-provoking situations with postexposure discussion may be helpful, as actual experience of real-life situations determines whether resolution of the abnormal emotional response has taken place.

  • Social problem-solving: The child or adolescent is encouraged to view the social interaction that causes anxiety as a problem to be solved; this technique can be especially helpful when combined with the use of positive reinforcers and fading of prompts.[52]

  • Modular treatment: A subset of CBT called MATCH-ADTC (Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems) may be an improvement over usual treatment according to one study. Researchers compared modular treatment to multiple community-implemented evidence-based treatments for youth with anxiety, depression, conduct problems, or traumatic stress. Participants were randomized to either MATCH-ADT or community-implemented treatment (CIT). Youth treated with MATCH showed significantly faster rates of improvement over time on clinical and functional outcomes relative to youth in the CIT condition and required significantly fewer sessions delivered over significantly fewer days. Caregiver-reported clinical improvement rates were significantly greater for MATCH (60%) versus CIT (36.7%).[11]

Consultations

To exclude hearing loss or other language disorder with selective mutism, obtain both a speech and language evaluation and an audiology evaluation.

If a more serious problem with interpersonal relatedness is suspected, the Childhood Autism Rating Scale (CARS) or other standardized tests may be administered by a licensed clinical psychologist to exclude childhood autism, pervasive developmental disorder, or reactive-attachment disorder. Autism and pervasive developmental disorders are behavioral diagnoses that can also be appropriately diagnosed by a pediatrician, behavioral/developmental pediatrician, pediatric neurologist, or, most appropriately, a multidisciplinary team.

Exclude suicidal behavior, self-harm, and a strong family history of suicide before treatment with paroxetine.

Diet

No specific dietary recommendations have proven efficacy in selective mutism.

Activity

Encouragement of continued normal activity is important to prevent behavioral and physical regression in skill levels in individuals with selective mutism.

Prevention

A recent case study article discussed the use of a manualized family-based CBT approach for very young (younger than 6 years old) children who scored in the concern range on a measure of shyness or anxiety as young as 26 months old.[53]

The use of internet-based approaches such as BRAVE has the potential to provide treatment to prevent worsening or additional associated symptoms of anxiety to persons that would otherwise not receive treatment.[54]

 

Medication

Medication Summary

SSRIs, especially fluoxetine, have demonstrated effectiveness for disabling social anxiety disorder and selective mutism. Experts postulate that SSRIs modulate anxiety symptoms both in the brain and peripherally in the gastrointestinal/autonomic nervous system. Peripheral gastrointestinal and autonomic nervous system activation account for the usual anxiety symptoms experienced (ie, cramping, dry mouth, tightness of the chest, palpitations, lightheadedness, dizziness). Drugs should be used only when symptoms significantly affect a patient's daily activities. Many people are mildly socially anxious, and only a small percentage need medication. Medical supervision including a cardiology consultation is advised if using a higher than usual dose range as may be needed to achieve symptom remission with SSRIs and SNRIs due to the increased risk of cardiac arrhythmia.[55]

Before starting treatment with SSRIs and whenever increasing or decreasing medication dosage, question the patient and family whether there is a prior history of self-harm and potentially suicidal behavior. When using SSRIs, suicidal behavior and a history of self-harm can be potential contraindications to treatment with fluoxetine (or other SSRIs or SNRIs). It is also important to ask about the presence of other conditions that could potentially worsen SSRI-induced hyponatremia.[2]

Selective serotonin reuptake inhibitors

Class Summary

These antidepressant agents are chemically unrelated to tricyclic, tetracyclic, or other available antidepressants. They inhibit CNS neuronal uptake of serotonin (5HT) and may have a weak effect on norepinephrine and dopamine neuronal reuptake. They have been used to treat anxiety, phobias, and obsessive-compulsive disorders.

These agents potentiate serotonergic activity in the CNS that results from inhibition of neuronal reuptake of serotonin and also block the influx of serotonin into platelets. Receptor and neurohistochemical changes result in changes in modulation of emotions.

SSRIs are greatly preferred over the other classes of antidepressants because of their increased tolerability, which tends to lead to improved compliance. Recent studies by the US Food and Drug Administration (FDA) have shown an association of increased risk of suicidal ideation or attempts with SSRIs. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with a mood disorder.

Physicians are advised to be aware of the following information and to use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric patients treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants. This is the largest study to date to address this issue.

The FDA continues to closely monitor the risk of suicidality, particularly in children younger than 18 years who are treated with antidepressants, antiseizure medications, mood stabilizers, and stimulants. Preliminary findings have shown that longer-acting antidepressants seem less likely to cause newly onset suicidality than shorter-acting antidepressants.[56]

A cohort study looked at suicide risk for individuals younger than 24 years in the context SSRIs and SNRIs antidepressant use in the context of the current “Black Box” warning regarding increased risk of suicidal ideation in this cohort.[57] This retrospective cohort study included 36,842 children aged 6-18 years enrolled in Tennessee Medicaid from 1995-2006 who were new users of 1 of the antidepressant medications of interest (defined as filling no prescriptions for antidepressants in the preceding 365 d). It found that there was increased risk for suicide attempts among users of multiple antidepressants concomitantly; however, there was no evidence of increased risk of suicide attempts when one medication was prescribed, and the adjusted rate of suicide attempts did not differ significantly among current users of SSRIs and SNRIs compared with current users of fluoxetine.[57]

Fluoxetine (Prozac)

DOC for social anxiety disorder because it has specific approval by the FDA for that disorder. DOC for selective mutism because this disorder is often associated with social anxiety disorder when untreated. Recommended to be administered bid to prevent withdrawal reactions. The FDA has not established the safety of this medication for children, except for those with major depressive disorders. Not recommended for use in children unless very closely supervised; FDA "Black Box" warning issued because of concerns about the risk of new-onset suicidal ideation, new-onset homicidal ideation, or self-injurious behavior. Clinical trials in the United Kingdom found a 1.5-3.2 times greater risk of self-harm and potentially suicidal behavior in children and teenagers treated with paroxetine than in those treated with placebo.

Generally, begin with 10 mg/d in divided doses bid because the half-life of the medication is 10-16 h after 1 dose and 21 h after multiple doses so that after the medication has been administered for 2-4 wk, once daily administration may give almost as good a blood level as twice daily dosage with improved patient compliance; increase dosage by not more than 10 mg/wk; morning administration recommended to minimize GI adverse effects; if giving syrup (10 mg/5 mL), instruct the parent on how to avoid overdosage. Steady-state levels take 2-6 wk to achieve.

Sertraline (Zoloft)

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. First SSRI used in children and adolescents. Relatively safe in overdose. May cause more gastrointestinal adverse effects than other SSRIs. May be given as a liquid or capsule. May give as once daily dose or in divided doses. Presence of food does not appreciably alter levels of the medication. May take up to 4-6 wk to achieve steady-state levels of the medication, as it has a long half-life. FDA approved in children 6 y and older for obsessive-compulsive disorder.

 

Follow-up

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.