Pediatric Social Phobia and Selective Mutism Workup

Updated: Oct 05, 2016
  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD  more...
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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 [31]

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. [32]

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. [33, 34]

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. [35]

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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. [32]
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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 [36]
  • Screening physical examination, including hearing testing and a screening neurologic examination - To exclude tumors or other disorders (eg, aphasia) [36]
  • ECG - To exclude any cardiac contraindication to medication treatment, such as a cardiac conduction abnormality or arrhythmia prior to medication treatment [29]
  • 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 [32]
  • 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. [37]
      • 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. [38]
      • 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. [39]
      • 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. [40]
      • 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. [41]
  • 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) [36]
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