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Selective mutism – Series of articles “How to treat the soul?” Part 27!

Selective mutism (SM), which occurs in approximately 1-2% of the child population, is an anxiety spectrum disorder and is characterized by failure to speak in specific situations, such as school, but unimpaired ability to speak and communicate in other settings, such as at home or with familiar peers . It has been observed that SM occurs more often in girls.
Studies show that the etiology of SM development is multifactorial – both genetic and environmental factors combine. The following risk factors for the development of SM have been identified:

1. Children with insecure attachment
2. Child hypercare
3. Over-controlling parents
4. Anxious parents with a tendency to avoid socialization
5. Closed, avoidant, shy temperament
6. Children with learning disabilities
7. Bilingual family
8. Immigrant status

SM mostly begins at the age of 2-4 years, but is diagnosed in preschool (ages 5-6) and in the first grades, because it causes significant impairments in social functioning and difficulties in acquiring knowledge. As children grow, selective mutism gradually diminishes until it disappears, but mild signs of SM may persist even in adulthood. According to the ISK-11 diagnostic criteria, the diagnosis of SM is established if the symptoms last for at least 1 month, and the child does not have a delay in language development or communication difficulties at school in connection with learning a foreign language. The diagnosis of selective mutism is not established in patients with a diagnosis of schizophrenia or autistic spectrum disorders.

In order to understand how best to help a child with SM, it is necessary to diagnose psychiatric comorbidities. Among the more commonly mentioned are social phobia, separation anxiety and generalized anxiety disorder. Less often, children with SM are diagnosed with obsessive compulsive disorder, dissociative disorder, depression, attention deficit hyperactivity disorder. SM should always be differentiated from neurodevelopmental disorders (autistic spectrum disorders, mental retardation, genetic diseases).
Considering the close comorbidity with anxiety spectrum disorders, the recommended treatment is:
1. Cognitive behavioral therapy (CBT) – with the aim of changing behavior and thinking patterns. Considering possible difficulties in communication with the child, it might be necessary to involve parents and teachers in the therapy, gradually increasing the individual communication between the therapist and the child.
2. Serotonin reuptake inhibitors (SSRIs), most commonly fluoxetine or sertraline.
3. Despite the fact that CBT and treatment with SSRIs are the most effective methods in the treatment of SM, it is also essential to involve an audiologist who would evaluate the child’s speech and language development and work with the diagnosed difficulties, thus training the use of language.

Author of the article: Child psychiatrist Agnese Údre.

Used sources:

1.Rozenek EB, Orlof W, Nowicka ZM, Wilczyńska K, Waszkiewicz N. Selective mutism – an overview of the condition and etiology: is the absence of speech just the tip of the iceberg? Psychiatr Pol. 2020 Apr 30;54(2):333-349. English, Polish. doi: 10.12740/PP/OnlineFirst/108503. Epub 2020 Apr 30. PMID: 32772064.

2. Reuther ET, Davis TE 3rd, Moree BN, Matson JL. Treating selective mutism using modular CBT for child anxiety: a case study. J Clin Child Adolesc Psychol. 2011;40(1):156-63. doi: 10.1080/15374416.2011.533415. PMID: 21229452.

3. Rodrigues Pereira C, Ensink JBM, Güldner MG, Lindauer RJL, De Jonge MV, Utens EMWJ. Diagnosing selective mutism: a critical review of measures for clinical practice and research. Eur Child Adolesc Psychiatry. 2023 Oct;32(10):1821-1839. doi: 10.1007/s00787-021-01907-2. Epub 2021 Dec 1. PMID: 34853909; PMCID: PMC10533577.

4. Oerbeck B, Overgaard KR, Stein MB, Pripp AH, Kristensen H. Treatment of selective mutism: a 5-year follow-up study. Eur Child Adolesc Psychiatry. 2018 Aug;27(8):997-1009. doi: 10.1007/s00787-018-1110-7. Epub 2018 Jan 22. PMID: 29357099; PMCID: PMC6060963.