Interactions between parenting styles, child anxiety, and oppositionality in selective mutism.

Selective mutism (SM) is a poorly understood condition, and debate continues regarding its etiology and classification. Research suggests that a genetic vulnerability may play a role in the development of the disorder which may be compounded by anxious and over-protective parenting. While previous studies supported the role of parenting styles in the development of SM, most of them examined child and parent factors in isolation. The current study examined how the interactions between child internalizing and externalizing behaviors (anxiety and oppositionality, respectively) and parenting styles (authoritative, permissive, and authoritarian) are associated with SM diagnosis. The study included 285 children aged 3-7 years (57.2% females), and their parents (66 children with SM and 219 typically developed children). Parents completed questionnaires about child social anxiety, oppositional behavior, SM severity, and their parenting style. Results showed that parents of children with SM reported lower levels of authoritative practices than those of typically developed children. We also found that child social anxiety and oppositionality moderated the effects of authoritative and authoritarian parenting practices on SM diagnosis. Our results suggest that child anxiety and oppositionality may explain the different susceptibility of children to adaptive and maladaptive parenting styles.

Symptoms of selective mutism beyond failure to speak in children and adolescents.

Understanding the symptoms of a mental disorder is essential for accurate diagnosis or selecting appropriate treatment targets. Despite this, there is a surprising lack of systematic research on the symptoms of selective mutism (SM). While the DSM-5 defines failure to speak as the only core symptom of SM, sparse research suggests that children with SM may experience additional symptoms. Previous studies have been limited in their identification of symptoms of SM, either by using a predefined set of symptoms or by only asking for anxiety-specific symptoms. This may have resulted in important symptoms being overlooked. In this study, we provided n = 86 parents of children and adolescents with SM (3-18 years) with a symptom definition appropriate for the target group. Additionally, parents were asked an open-ended question about any other symptoms they had observed in their children, beyond the failure to speak. The symptoms reported were categorized using qualitative content analysis (QCA) and examined for frequency and association with symptom severity. Ten different symptom categories were identified, with fear, freezing, and avoidance/security behaviors being the most prevalent. On average, parents reported M = 4.74 (SD = 2.37) symptoms from different symptom categories. Only fear was found to be related to symptom severity of SM. As the findings suggest that SM encompasses various symptoms beyond failure to speak, a more sophisticated understanding of SM as a mental disorder with multiple symptoms seems essential. The clinical implications of this are discussed in further detail.

Can We Be Creative with Communication? Assessing Decision-Making Capacity in an Adult with Selective Mutism.

Selective mutism is an anxiety disorder in which an individual is unable to speak in certain social situations though may speak normally in other settings (Hua & Major, 2016). Selective mutism in adults is rare, though people with this condition might have other methods of communicating their needs outside of verbal communication. Healthcare professionals rely on a patient's ability to communicate to establish if they have decision-making capacity. This commentary responds to a case of a young adult patient with selective mutism and social anxieties that significantly limited his ability to communicate with anyone in the healthcare team. This required a creative, patient-centered approach to engage in meaningful communication.

Long-term outcomes of selective mutism: a systematic literature review.

BACKGROUND: Selective mutism (SM) is a childhood onset anxiety disorder, and the main symptom is not speaking in certain social situations. Knowledge about the duration and long-term outcomes of SM have been lacking and the aim of this systematic literature review was to address this gap in the literature. We investigated how long SM symptoms persisted as well as other psychiatric outcomes associated with SM in later life. METHODS: The PubMed, PsycInfo, Web of Science, Cochrane Library and Embase databases were initially searched from inception to 11 September 2023. Studies were included if they were published in English and had followed up subjects with clinically diagnosed SM for at least two years. The review followed the Preferred Reporting Items of Systematic Reviews and Meta-analyses guidelines and the protocol was registered with the Open Science Framework. The papers were assessed using the Quality Assessment with Diverse Studies tool. RESULTS: This review screened 2,432 papers and assessed 18 studies. Seven case series studies were excluded from discussion because of the low number of subjects and the fact that their findings could not be generalized to wider populations. In the end, nine clinical cohorts and two case control studies were reviewed. These provided a total of 292 subjects and the sample sizes ranged from 11-49. The overall quality of the studies was moderate. The review found that 190 of the 243 subjects in the studies that reported recovery rates showed moderate or total improvement from SM during follow up. Other anxiety disorders were the most common psychiatric disorders later in life, although these results should be interpreted with caution. Older age at baseline and parental psychopathology might predict greater impairment, but further studies are needed to confirm these results. CONCLUSIONS: Most subjects with SM recovered from this disorder during adolescence, but anxiety disorders were common in later life. Early detection and treatment are needed to prevent symptoms from persisting and other psychiatric disorders from developing.

Diagnosing selective mutism: a critical review of measures for clinical practice and research.

Selective mutism (SM) is an anxiety disorder (prevalence 1-2%), characterized by the consistent absence of speaking in specific situations (e.g., in school), while adequately speaking in other situations (e.g., at home). SM can have a debilitating impact on the psychosocial and academic functioning in childhood. The use of psychometrically sound and cross-culturally valid instruments is urgently needed.The aim of this paper is to identify and review the available assessment instruments for screening or diagnosing the core SM symptomatology. We conducted a systematic search in 6 databases. We identified 1469 studies from the last decade and investigated the measures having been used in a diagnostic assessment of SM. Studies were included if original data on the assessment or treatment of SM were reported. It was found that 38% of published studies on SM reporting original data did not report the use of any standardized or objective measure to investigate the core symptomatology. The results showed that many different questionnaires, interviews and observational instruments were used, many of these only once. The Selective Mutism Questionnaire (SMQ), Anxiety Disorders Interview Schedule (ADIS) and School Speech Questionnaire (SSQ) were used most often. Psychometric data on these instruments are emerging. Beyond these commonly used instruments, more recent developed instruments, such as the Frankfurt Scale of SM (FSSM) and the Teacher Telephone Interview for SM (TTI-SM), are described, as well as several interesting observational measures. The strengths and weaknesses of the instruments are discussed and recommendations are made for their use in clinical practice and research.

Long-term outcome of selective mutism: factors influencing the feeling of being cured.

Some long-term outcomes for participants with selective mutism (SM) are elevated rates of phobic disorders, particularly social phobia, persistent communicative problems, and reduced self-esteem. However, data on the long-term outcomes of SM are scarce. In this study, by analyzing interpersonal anxiety, communication skills, and self-esteem among those who experienced SM and felt cured (SM-C-group: 30 females, 6 males, mean age 28.0, SD = 7.42, range 19-47 years), those who experienced SM and did not feel cured (SM-NC-group: 37 females, 4 males, mean age 27.4, SD = 7.24, age range 19-50 years), and those who had not experienced SM (Non-SM-group: 30 females, 30 males, mean age 26.4, SD = 7.62, age range: 20-48 years), we examined the long-term outcomes of SM and the factors that influence the feeling of being cured of SM. Results showed that the SM-C-group and SM-NC-groups had significantly higher interpersonal anxiety and significantly lower communication skills than the Non-SM-group. Moreover, the SM-C-group showed significantly lower interpersonal anxiety and significantly higher communication skills than the SM-NC-group. However, while there was no significant difference in self-esteem between the SM-C and SM-NCgroups, there was a significant difference between the SM-NC and Non-SM groups. The SM-C and SM-NC groups did not differ on the retrospective symptom load (SMQ-J), but did on the Current level of difficulty with speaking. The results of the logistic regression analysis predicted that communication skills and self-esteem did not influence the feeling of being cured of SM, but interpersonal anxiety and Current level of difficulty to speak did. Therefore, it is speculated that the intensity of this interpersonal anxiety and whether people with SM still felt difficulty in talking to others may have affected the feeling of being cured from SM.

Clinical characteristics according to sex and symptom severity in children with selective mutism: a four-center study.

INTRODUCTION: Clinical information regarding selective mutism (SM), a persistent and debilitating psychiatric disorder, in children is extremely limited. We aimed to examine sociodemographic characteristics and comorbid psychiatric conditions and identify clinical variables associated with sex and SM severity among children with SM. METHODS: We analyzed the medical records of 49 children who received treatment for SM in four different tertiary hospitals in Turkey between 2016 and 2021. Children's charts were reviewed to examine clinical characteristics, comorbidities, and response to treatment. RESULTS: Thirty-one children were female, and 18 were male (female:male ratio is 1.7:1). Most children (73.5%) with SM displayed onset of SM in 3-6 years. However, most children (57.1%) were diagnosed between the ages of 7-11. The mean time from onset to diagnosis was 1.69 ± 1.37 years. Females displayed a later onset of SM (6.42 ± 2.40 vs. 4.89 ± 0.96; p= 0.013) and higher comorbidity rates (71% vs. 38.9%, p= 0.039) than males. The vast majority of children received two or more psychiatric diagnoses. Children in the severe group had a longer duration of illness, higher rates of psychiatric comorbidity, speech delay, and treatment resistance. CONCLUSION: Our study suggests that SM may have different clinical features according to sex and symptom severity of SM. More information about children with SM is needed to understand the development and maintenance of SM.

An Updated Characterization of Childhood Selective Mutism: Exploring Clinical Features, Treatment Utilization, and School Services.

Selective mutism (SM) is a severe but understudied childhood anxiety disorder. Most epidemiological research on SM was conducted decades ago and is limited by small sample sizes. This study analyzes parent-reported clinical data from 230 children with diagnosed and suspected SM to provide current information about the presentation of this disorder. Overall, anxiety and social anxiety symptoms were elevated. Gender ratio, comorbidities and family history of psychopathology were generally aligned with previous research. However, age of onset and diagnosis were both earlier than previously reported, with an average delay of 2 years between onset and diagnosis. The majority of children received therapy and school accommodations for their SM, yet there was large variability in types of interventions. This is the largest survey of children with SM conducted primarily within the US and it constitutes the first systematic inquiry into interventions and accommodations received within clinical and school settings.

Symptoms of Selective Mutism in Middle Childhood: Psychopathological and Temperament Correlates in Non-clinical and Clinically Referred 6- to 12-year-old Children.

The purpose of this study was to study psychopathological and temperamental correlates of selective mutism (SM) (symptoms) in a mixed sample of non-clinical (n = 127) and clinically referred (n = 42, of whom 25 displayed the selective non-speaking behavior that is prototypical for SM) 6- to 12-year-old children. Parents completed questionnaires to measure their child's symptom levels of selective mutism, social anxiety, autism spectrum disorder, and the temperament trait of behavioral inhibition. The results first and foremost showed that SM symptoms were clearly linked to social anxiety and an anxiety-prone temperament (behavioral inhibition), but findings also suggested that autism spectrum problems are involved in the selective non-speaking behavior of children. While the latter result should be interpreted with caution given the methodological shortcomings of this study, findings align well with the notion that SM is a heterogeneous psychiatric condition and that clinical assessment and treatment need to take this diversity into account.

Characteristics of person, place, and activity that trigger failure to speak in children with selective mutism.

Selective Mutism (SM) is an anxiety disorder with predictable and circumscribed situations in which children remain silent while they speak unaffectedly in others. However, core features of anxiety inducing stimuli have rarely been studied so far. Parents of children with elevated SM symptomatology participated in an online-based study and answered open ended questions about specific characteristics of a person, place, and activity that elicit failure to speak in their child. The final sample consisted of n = 91 parents with children aged between 3 and 17 years (M = 8.02 years, SD = 3.94). Answers were analyzed by qualitative content analysis. Characteristics of a person were assigned to five categories with lack of distance as the most frequently reported feature. With respect to a place, the majority of parents mentioned unknown places as a silence trigger. The most frequently mentioned feature of an activity that was designated to be associated to silence was new activity. There were only few associations between the designation of these features, age, and gender. For the first time, anxiety inducing triggers related to person, place, and activity were comprehensively assessed in children with SM. This allows a differentiated and deeper understanding of an understudied disorder. The majority of characteristics can be associated with proposed etiological factors such as increased behavioral inhibition, conditioning processes, social anxiety, and a strong need for control. Implications for effective treatments are discussed.

Selective mutism and the risk of mental and neurodevelopmental disorders among siblings.

The siblings of children with mental disorders are more likely to experience mental health issues themselves, but there has been a lack of sibling studies on selective mutism (SM). The aim of this population-based study was to use national registers to examine associations between children with SM and diagnoses of various mental disorder in their siblings. All singleton children born in Finland from 1987 to 2009, and diagnosed with SM from 1998 to 2012, were identified from national health registers and matched with four controls by age and sex. Their biological siblings and parents were identified using national registries and the diagnostic information on the siblings of the subjects and controls was obtained. The final analyses comprised 658 children with SM and their 1661 siblings and 2092 controls with 4120 siblings. The analyses were conducted using generalized estimating equations. Mental disorders were more common among the siblings of the children with SM than among the siblings of the controls. The strongest associations were observed for childhood emotional disorders and autism spectrum disorders after the data were adjusted for covariates and comorbid diagnoses among SM subjects. The final model showed associations between SM and a wide range of disorders in siblings, with strongest associations with disorders that usually have their onset during childhood. Our finding showed that SM clustered with other mental disorders in siblings and this requires further research, especially the association between SM and autism spectrum disorders. Strong associations with childhood onset disorders may indicate shared etiologies.

The Validation of the Selective Mutism Questionnaire for Use in the Dutch Population.

Selective mutism (SM) is an anxiety disorder in children/adolescents, characterized by the absence of speaking in specific social situations, mostly at school. The selective mutism questionnaire (SMQ) is a parent report, internationally used to assess SM symptomatology and treatment outcomes. Since no assessment instrument for SM was available in the Netherlands, our aim was to investigate the psychometric properties of the Dutch translation of the SMQ, through reliability, confirmatory factor, and ROC analyses conducted on data obtained in 303 children (ages 3-17 years; clinical SM group n = 106, control group n = 197). The SMQ turned out to be highly reliable (α = 0.96 in the combined sample; 0.83 within the clinical group) and followed the expected factor structure. We conclude that the Dutch version of the SMQ is a reliable and valid tool both as a screening and clinical instrument to assess SM in Dutch speaking children.

Betrayed by the nervous system: a comparison group study to investigate the 'unsafe world' model of selective mutism.

The study presented in the following verifies some assumptions of the novel 'unsafe world' model of selective mutism (SM). According to this model, SM is a stress reaction to situations erroneously experienced via cognition without awareness as 'unsafe'. It assumes a high sensitivity to unsafety, whereby the nervous system triggers dissociation or freeze mode at relatively low thresholds. We examine whether there is a correlation between SM, sensory-processing sensitivity and dissociation. We compared a sample of 28 children and adolescents with SM (mean age 12.66 years; 18 females) to 33 controls without SM (mean age 12.45 years; 21 females). Both groups were compared using a medical history sheet, the 'Selective Mutism Questionnaire' (SMQ), a 'Checklist for Speaking Behaviour' (CheckS), the 'Highly Sensitive Person Scale' (HSPS), the 'Child Dissociative Checklist' (CDC), the 'Adolescent Dissociative Experience Scale' (A-DES) and the 'Social Phobia and Anxiety Inventory for Children' (SPAIK). Appropriate parametric and non-parametric tests were conducted to examine differences between groups. The results indicate that sensory-processing sensitivity was significantly higher in the group of children and adolescents with SM [X2(1) = 7.224, p = 0.0007; d = 1.092]. Furthermore, dissociative symptoms were more common in children and adolescents with SM than in controls [F(1, 33) = 13.004, p = 0.001; d = 0.986]. The results indicate that sensory-processing sensitivity and dissociation are important factors of SM that may hold important implications for the treatment. TRIAL REGISTRATION: This study is registered with the ClinicalTrials.gov number NCT04233905.

Psychiatric Symptoms as the First or Solitary Manifestation of Somatic Illnesses: Hyperammonaemia Type II.

AIM: We describe the difficulties encountered in making a diagnosis where a somatic condition manifests itself alongside psychiatric symptoms associated with possible psychiatric comorbidities. METHODS: A case study is presented of a 15-year-old girl who was eventually diagnosed with ornithine transcarbamylase (OTC) deficiency (hyperammonaemia type II), following an initial diagnosis of pervasive developmental disorder, selective mutism, and anorexia nervosa. RESULTS: The OTC disease is not fully expressed in females and its prevalence is lower than in males. Around 17-20% of female patients found with a defective OTC gene on an X chromosome can suffer from OTC deficiency that may result in elevated levels of ammonia in the blood; this occurs when one of the X chromosomes become inactivated. Patients typically present with nausea, migraines, and a history of dietary protein avoidance. In more severe cases, ataxia, confusion, hallucinations, and cerebral oedema can occur. The OTC deficiency can thus remain undiagnosed in women for many years. CONCLUSION: Somatic comorbidity in psychiatric inpatients is commonly found; however, such disorders are rarely diagnosed or even treated adequately.

Distinguishing selective mutism and social anxiety in children: a multi-method study.

Selective mutism (SM) is an anxiety disorder in which a child fails to speak in some situations (e.g., school) despite the ability to speak in other situations (e.g., home). Some work has conceptualized SM as a variant of social anxiety disorder (SAD) characterized by higher levels of social anxiety. Here, we empirically tested this hypothesis to see whether there were differences in social anxiety (SA) between SM and SAD across behavioral, psychophysiological, self-, parent-, and teacher-report measures. Participants included 158 children (Mage = 8.76 years, SD = 3.23) who were classified into three groups: children with SM and who were also highly socially anxious (SM + HSA; n = 48), highly socially anxious children without SM (HSA; n = 48), and control children (n = 62). Children participated in a videotaped self-presentation task, following which observed SA behaviors were coded, and salivary cortisol reactivity was measured. We also collected child, parent, and teacher reports of children's trait SA symptoms. The SM + HSA and HSA groups had similar observed non-verbal SA behavior, cortisol reactivity, and trait SA symptom levels according to parent and child reports, but SM + HSA children had significantly higher SA according to teacher report and observer-rated verbal SA behavior relative to the HSA group. As expected, control children had lower cortisol reactivity and SA across all measures relative to the other groups. Although SM and SAD in children share many similarities, SM may be characterized by greater SA in certain social contexts (e.g., school) and is distinguishable from SAD on behavioral measures of verbal SA.

Efficacy of psychological interventions for selective mutism in children: A meta-analysis of randomized controlled trials.

BACKGROUND: Selective mutism is a rare childhood anxiety disorder characterized by a consistent failure to speak in certain social situations where speech is expected, despite fluent speech in other situations. The purpose of this meta-analysis was to investigate the efficacy of psychological interventions for selective mutism in randomized controlled trials (RCTs). METHODS: Five RCTs with a total of 233 participants were analysed using a random-effects model. A quality assessment of the included studies revealed that psychometrically sound measures and treatment manuals were used across all studies. RESULTS: The results of the analyses showed psychological interventions to be more effective than no treatment, with the overall weighted effect size of g = 0.87, indicating a large mean treatment effect. This effect did not significantly differ with whether only selective mutism specific or nonselective mutism specific measures were included in the analysis. CONCLUSIONS: These findings provide support for the efficacy of psychological treatment for selective mutism. Future research could examine the effects of the successful treatments identified in this meta-analysis when compared with a psychological placebo or another bona fide treatment.

The impact of parental psychopathology and sociodemographic factors in selective mutism - a nationwide population-based study.

BACKGROUND: Selective mutism (SM) is nowadays considered a relatively rare anxiety disorder characterized by children failing to speak in certain situations. Research on risk factors for SM are limited in comparison to other psychiatric disorders. The aim of this study was to examine several potential risk factors for SM in a large nationwide cohort, namely parental psychopathology, parental age, maternal SES, urbanicity, maternal marital status and parental immigration status. METHODS: This nested case-control study comprised 860 cases with SM, identified from the Finnish Hospital Discharge Register and 3250 controls matched for sex and age from the Finnish Central Population Register. Conditional logistic regression was used to examine the association between the risk factors and SM. RESULTS: If both parents had any psychiatric disorder, this almost tripled their odds of having a child with SM (OR 2.8, 95% CI 2.0-4.0). There were increased rates of all types of psychiatric disorders in the parents of the children with SM, with a wider range of diagnoses among the mothers than fathers. Fathers over 35 years (OR 1.4, 95% CI 1.1-1.8) were significantly more likely to have children with SM. Offspring of a single mother had a 2-fold (OR = 2.0, 95% CI 1.4-3.0) increased odds of SM than mothers who were married or in a relationship. CONCLUSIONS: Several parental psychiatric disorders were associated with offspring SM. This points towards a shared aetiology of psychiatric disorders. Findings on paternal age and single motherhood help to improve our understanding of risk factors for SM.

Current and Novel Psychopharmacological Drugs for Anxiety Disorders.

Anxiety disorders, including panic disorder/agoraphobia (PDA), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and others, are the most prevalent mental disorders. In this paper, recommendations are given for the psychopharmacological treatment of these disorders which are based on comprehensive treatment guidelines, meta-analyses, and systematic reviews of available randomized controlled studies. Anxiety disorders can effectively be treated with psychotherapy, pharmacotherapy, or a combination of both. First-line drugs are the selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Benzodiazepines are not recommended for routine use due to their possible addiction potential. Other treatment options include the calcium modulator pregabalin, tricyclic antidepressants, buspirone, moclobemide, and others. Drug treatment can be combined with psychological treatments. Novel treatment strategies include medications that act on GABA, glutamate, and other neurotransmitter systems. After remission, medications should be continued for 6 to 12 months.

Anxiety in Children with Selective Mutism: A Meta-analysis.

This study evaluates the current conceptualization of selective mutism (SM) as an anxiety disorder in the DSM-5 using a meta-analytic approach. In the absence of any systematic assessment of anxiety in the field of SM, we pooled prevalence data of comorbid anxiety disorders in a random-effects meta-analysis. On the basis of 22 eligible studies (N = 837), we found that 80% of the children with SM were diagnosed with an additional anxiety disorder, notably social phobia (69%). However, considerable heterogeneity was present, which remained unexplained by a priori specified moderators. The finding that SM is often diagnosed in combination with anxiety disorders, indicates that these disorders are not discrete, separable categories. Moreover, this finding does not help to elucidate the relation between SM and anxiety as an etiological mechanism or symptomatic feature. Broadening our research strategies regarding the assessment of anxiety is paramount to clarify the role of anxiety in SM, and allow for proper classification.

Fears and fear-related cognitions in children with selective mutism.

Selective mutism (SM) is classified under the category of anxiety disorders in DSM-5 [1], although concrete fears that underlie the condition are not specified contrary to all other anxiety disorders. Given the lack of studies systematically investigating fears in SM, content and frequency of concrete fears as well as related cognitions have remained unclear so far. One hundred and twenty-four participants [M = 13.25 years (SD = 3.24), range 8-18 years] with SM (n = 65), social phobia (SP n = 18) or with typical development (TD n = 51) took part in an online survey. Participants with SM (n = 65) answered an open-ended question concerning fears that might cause the consistent failure to speak in select situations. Additionally, participants with SM, SP and TD completed a survey containing 34 fear-related cognitions that might occur in speech-demanding situations. Open text answers were systematically evaluated by extracting higher-order categories using a Qualitative Content Analysis. Single item scores of the survey were compared between the three groups. 59% of all spontaneously reported fears were assigned to the cluster of social fears. Other reported fears represented the categories fear of mistakes (28%), language-related fears (8%) and voice-related fears (5%). The SM- and SP group only differed regarding the cognition that one's own voice might sound funny (SM > SP). Social fears and the fear of mistakes account for the majority of fears in SM. Therefore, future interventions should consider specifically targeting these types of fears.