Practical guidelines for the assessment and treatment of selective mutism

OBJECTIVE: To provide practical guidelines for the assessment and treatment of children with selective mutism, in light of the recent hypothesis that selective mutism might be best conceptualized as a childhood anxiety disorder. METHOD: An extensive literature review was completed on the phenomenology, evaluation, and treatment of children with selective mutism. Additional recommendations were based on clinical experience from the authors' selective mutism clinic. RESULTS: No systematic studies of the phenomenology of children with selective mutism were found. Reports described diverse and primarily noncontrolled treatment approaches with minimal follow-up information. Assessment and treatment options for selective mutism are presented, based on new hypotheses that focus on the anxiety component of this disorder. Ongoing research suggests a role for behavior modification and pharmacotherapy similar to the approaches used for adults with social phobia. CONCLUSION: Selectively mute children deserve a comprehensive evaluation to identify primary and comorbid problems that might require treatment. A school-based multidisciplinary individualized treatment plan is recommended, involving the combined effort of teachers, clinicians, and parents with home- and clinic-based interventions (individual and family psychotherapy, pharmacotherapy) as required.     

Linguistic focus affects eye movements during reading

OBJECTIVE: To clarify the diagnostic significance of selective mutism (elective mutism in DSM-III-R). METHOD: Fifty children with selective mutism were evaluated systematically by means of semistructured clinical interviews and rating scales to obtain detailed diagnostic information. RESULTS: All 50 children met DSM-III-R criteria for social phobia or avoidant disorder and 24 (48%) had additional anxiety disorders. Clinical measures of anxiety and behavioral symptoms supported the presence of anxiety disorders as a characteristic of selectivity mute children. Only one case each of oppositional defiant disorder and attention-deficit hyperactivity disorder was found. CONCLUSIONS: Persistent selective mutism typically presents in the context of anxiety disorders.     

Selective mutism: A review of the treatment literature by modality from 1980–1996.

Psychodynamic, family systems, behavioral, and psychopharmacological interventions of selective mutism are reviewed and discussed to examine effectiveness of treatment styles. Each modality has its own conceptualization of the disorder and specialized intervention techniques. While methodologies of the studies reviewed were often weak, there exist many treatment examples that illustrate effective interventions for selective mutism in childhood. The interventions that involved individualized or multimodal treatments produced the best overall results as evidenced through the symptom cessation. Many articles reported a close relationship between selective mutism and anxiety disorders. A clearer diagnostic understanding of selective mutism needs to be realized prior to generalizing a specific, effective treatment for this disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

MCMI-II personality traits and symptom traits in parents of children with selective mutism: A case-control study.

The etiology of selective mutism (SM) in children is unknown but is regarded as multifactorial. SM is frequently associated with social anxiety and language disorder or delay. The present study addresses SM and social anxiety as a familial phenomenon by comparing self-reported personality traits and symptom traits (Millon Clinical Multiaxial Inventory; T. Millon, 1987) in parents of 50 SM children with control parents. Personality and symptom traits reflecting social anxiety are also explored separately in the parents of SM children with and without a comorbid communication disorder. The results confirm SM and social anxiety as a familial phenomenon. Assessment and treatment planning should take this into account. The family data also suggest different family transmissions of SM and social anxiety in the SM group with and without a comorbid communication disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of selective mutism: A best-evidence synthesis.

This study represents the first systematic analysis of the major treatment approaches used for selective mutism with the goal of drawing conclusions about selecting evidence-based procedures for practice. Based on nonparametric statistical tests of effect sizes, the major findings include the following: (a) treatment of selective mutism is more effective than no treatment, (b) behaviorally oriented treatment approaches are more effective than no treatment, and (c) no differential effectiveness was found between two common models of behavior therapy. In addition, researchers have given minimal attention to the impact of selective mutism on educational performance. In this study, which reviewed existing research, information regarding academic achievement was evaluated qualitatively. Recommendations are made for improving the methodological quality of future research on selective mutism within the context of research on evidence-based interventions. Implications for practice in school psychology are presented. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Transient "cerebellar" mutism

The term "cerebellar mutism" refers to a specific disorder in which a complete but transient loss of speech, followed by dysarthria, occurs following resection of intrinsic posterior cranial fossa tumors or cerebellar hemorrhages, or upon trauma. Although it is well known that the lack of long-tract findings and cranial nerve (CN) involvement is the rule, the pathophysiology of cerebellar mutism has not been clearly elucidated. A review of the relevant literature disclosed 93 patients with this condition, the majority of these being in the pediatric age group. The neuropathological findings were as follows: 57 primitive neuroectodermal tumors (PNET), 19 astrocytomas, 10 ependymomas, 5 vascular malformations, 1 metastatic tumor, and 1 traumatic injury. The interval before the onset of mutism ranged from 0 to 168 h (mean 40.9 h). The mutism lasted from 1 to 168 days (mean 37.6 days). Subsequent dysarthria was present in 75 (80%) of the 93 patients. In this article, some specific recent illustrative reports are presented, and the concept of the role of the cerebellum in language and cognition is discussed. With these data as our point of departure, various hypotheses that have been advanced to explain the pathogenesis of this transient speech disorder are analyzed. The findings of the study suggest that the cause of the cerebellar mutism is the ischemia caused by vasospasm, as it usually developed after a latent period.     

Selective mutism: Phenomenological characteristics.

Examined the phenomenological characteristics of selective mutism (SM) in the following areas: (1) mute and variant talking patterns occurring prior to the identification of SM and/or that occur as conditions within SM, (2) events that precipitate SM, (3) biological vulnerabilities of SM in terms of anxiety and temperament, (4) characteristics associated with SM, (5) other problems experienced with SM, and (6) school and social competencies. Surveys were conducted with or for 153 people (aged 2–72 yrs) who had experience with SM. Results support the existence of variant talking behaviors (talking with less frequency, volume, and spontaneity than usual), in addition to mutism, prior to the identification of SM and as part of the SM syndrome. Setting (home, school, community) affected the rate of occurrence for mute and variant talking behaviors. Evidence supported a link between SM and social anxiety or phobia. Support was found for the idea that persons with SM have have characteristics similar to behaviorally inhibited or slow-to-warm children, suggesting a potential link between temperament and SM. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The treatment of elective mutism as stranger reaction.

Discusses the treatment of 15 preschool children with elective mutism (EM), which involves a fixation at or a regression to an earlier developmental stage when children typically exhibit stranger anxiety. It is suggested that the treatment of EM children should be determined by developmental considerations as well as etiological theories and that treatment should focus on unblocking of maturational processes. Treatment techniques and setting are described. Case examples illustrate that there were subtypes of EM children who were compliant and who were noncompliant and aggressively avoidant. The former responded to slow, psychodynamically oriented treatment and the latter responded to group therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Long-term cognitive deficits following posterior fossa tumor resection: A neuropsychological and functional neuroimaging follow-up study.

The posterior fossa syndrome (PFS) consists of transient cerebellar mutism, cognitive symptoms, and neurobehavioral abnormalities that typically develop in children following posterior fossa (PF) tumor resection. The pathophysiological substrate of the syndrome remains unclear. We investigated eight children of whom five presented with a variety of clinically relevant non-motor language symptoms associated with cognitive and behavioral disturbances after PF tumor resection. Four children developed transient cerebellar mutism followed by dysarthric speech. Non-motor language symptoms consisted of agrammatism, anomia, impaired verbal fluency, comprehension deficits, and aspontaneous speech. Neurocognitive deficits included executive dysfunctions, concentration deficits, and visuo-spatial disorders. In addition, all children presented with behavioral and affective disturbances. Functional neuroimaging studies during the phase of mutism by means of SPECT showed perfusional deficits in the anatomo-clinically suspected supratentorial areas subserving language dynamics, syntax, naming, executive functioning, affective regulation, and behavior. A significant improvement of frontal perfusional deficits paralleled the clinical remission of mutism. These results add to the view that the PFS might represent a cerebello-cerebral diaschisis phenomenon, reflecting the metabolic impact of the cerebellar lesion on supratentorial cognitive and affective functions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Elective mutism: an analysis of 100 cases

OBJECTIVE: An extended series of 100 children with elective mutism (EM) was clinically analyzed. METHOD: The total sample included two subgroups of clinically referred children at different locations and a subgroup of nonreferred children with EM. The study was based on comprehensive item sheets and, in the nonreferred sample only, the Child Behavior Checklist. RESULTS: EM is a rare disorder in the referred child psychiatric samples. It typically starts at preschool age, is more common in girls, and is seen in all social strata. A background of migration and early developmental risk factors is also quite common. Premorbid speech and language disorders play a role in one third of the clientele, and three quarters of children with EM had behavioral abnormalities during infancy and preschool age. School and unfamiliar people create the social context in which children with EM most frequently do not speak. Shyness and internalizing behavior problems are the most common personality features in EM, and comorbid diagnoses are quite frequent. CONCLUSION: This large series of affected children has identified the most typical features of EM and thereby extends the limited knowledge of this rare disorder of childhood.     

HOPE for battered women with PTSD in domestic violence shelters.

Do you feel overwhelmed when attempting to treat battered women with ongoing safety concerns? Could battered women in shelters benefit from psychotherapy in addition to the case management they traditionally receive? What type of treatment would be most beneficial for battered women in shelters? Posttraumatic stress disorder (PTSD) is the most prevalent disorder associated with intimate partner violence (IPV). PTSD is associated with severe impairment and loss of resources, which can severely impact a sheltered battered woman’s ability to establish long-term safety for herself and her children. Consequently, we have developed a new treatment for sheltered battered women with PTSD, Helping to Overcome PTSD through Empowerment (HOPE). HOPE is a short-term cognitive-behavioral treatment in a preliminary stage of development for battered women with PTSD in domestic violence shelters. It focuses on stabilization, safety, and empowerment and teaches women skills to manage their PTSD symptoms that may interfere with their ability to access important community resources and establish safety for themselves and their children. A case example utilizing HOPE is offered. Future directions and clinical applications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mediators and moderators of a psychosocial intervention for children affected by political violence.

Objective: The authors examined moderators and mediators of a school-based psychosocial intervention for children affected by political violence, according to an ecological resilience theoretical framework. Method: The authors examined data from a cluster randomized trial, involving children aged 8–13 in Central Sulawesi, Indonesia (treatment condition n = 182, waitlist control condition n = 221). Mediators (hope, coping, peer/emotional/play social support) and moderators (gender, age, family connectedness, household size, other forms of social support, exposure to political violence, and displacement) of treatment outcome on posttraumatic stress symptoms and function impairment were examined in parallel process latent growth curve models. Results: Compared with the waitlist group, those receiving treatment showed maintained hope, increased positive coping, maintained peer social support, and increased play social support. Of these putative mediators, only play social support was found to mediate treatment effects, such that increases in play social support were associated with smaller reductions in posttraumatic stress disorder (PTSD) symptoms. Furthermore, the authors identified a number of moderators: Girls showed larger treatment benefits on PTSD symptoms; girls, children in smaller households, and children receiving social support from adults outside the household showed larger treatment benefits on function impairment. Conclusions: Findings provide limited evidence for an ecological resilience theoretical framework. On the basis of these findings, the authors recommend a stronger separation between universal prevention (e.g., resilience promotion through play) and selective/indicated prevention (e.g., interventions aimed at decreasing posttraumatic stress symptoms). Play-based interventions should be careful to exclude children with psychological distress. In addition, treatment effects may be augmented by selecting girls and socially vulnerable children. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Childhood mania: insights into diagnostic and treatment issues

Our study's objective was to clarify the nosologic status of children who satisfy diagnostic criteria for bipolar disorder. Using blind raters and structured psychiatric interviews as well as data from other instruments, we undertook studies from various vantage points, examining children with bipolar disorder to confirm the existence of the diagnosis in children and to clarify its clinical course and characteristics. We found that (1) bipolar disorder in children referred to our clinical center is not as rare as previously thought; (2) bipolar disorder in children commonly presents with attention-deficit hyperactivity disorder, which makes diagnosis difficult; and (3) bipolar disorder in children presents with a clinical picture considered atypical by adult standards, with irritability, chronicity, and symptoms of mania mixed with those of depression. Our data suggest that childhood bipolar disorder is more common than previously thought, but it may be difficult to diagnose because of comorbidity with attention-deficit hyperactivity disorder and a developmentally different presentation from adults.     

Behavior therapy for Tourette's disorder: Utilization in a community sample and an emerging area of practice for psychologists.

The current article describes the phenomenology and empirically supported treatments for Tourette's disorder (TD) and presents data on treatment utilization from two separate national surveys of adults with TD (N = 672) and parents of children with TD (N = 740). Despite a wealth of empirical evidence demonstrating its effectiveness, results suggest that most people with TD do not receive behavior therapy for the condition. Reasons for this include a lack of information about the disorder among consumers and providers, a shortage of providers trained in the treatment, and concern about possible negative effects of behavioral treatment. The article concludes with a discussion about dissemination efforts aimed at making behavior therapy more widely available to children and adults with chronic tics and a review of beliefs about the negative effects of behavior therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Helping child flood victims using group EMDR intervention in Argentina: Treatment outcome and gender differences.

A comprehensive group intervention with 124 children who experienced disaster-related trauma during a massive flood in Santa Fe, Argentina, in 2003 is illustrated, utilizing a one-session group eye movement desensitization and reprocessing (EMDR) protocol. A posttreatment session was done 3 months after the treatment intervention to evaluate results. Results of this one-session treatment procedure, utilizing the EMDR-Integrative Group Treatment Protocol, showed statistically significant reduction of symptoms immediately after the intervention. These statistically significant differences were sustained at posttreatment evaluation 3 months later, as measured by psychometric scales, and by clinical and behavioral observation. Data analysis also revealed significant gender differences. Despite methodological limitations, this study supports the efficacy of EMDR group treatment in the amelioration and prevention of posttraumatic stress disorder symptoms, providing an efficient, simple, and economic (in terms of time and resources) tool for disaster-related trauma. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychopharmacology of aggression in children and adolescents with primary neuropsychiatric disorders: A review of current and potentially promising treatment options.

Research examining the role of pharmacological therapy in the treatment of children and adolescents with clinical disorders is growing. Clinical disorders that present with comorbid aggression can add a challenge to treatment. Child and adolescent neuropsychiatric disorders associated with aggression include attention-deficit hyperactivity disorder, various mood disorders and in particular bipolar disorders/pediatric mania, schizophrenia, mental retardation, oppositional defiant disorder, conduct disorder, and autism spectrum disorders. This review describes the psychopharmacy to treat these disorders and the aggression that often appears comorbidly. Existing literature regarding the efficacy and safety of psychotropics for youth with neuropsychiatric disorders also is discussed. In addition, general guidelines for psychopharmacy of aggression in children and adolescents are presented. Studies reviewed in this article provide evidence for the use of psychostimulants, alpha-2 agonists, beta blockers, lithium, anticonvulsant mood-stabilizers, atypical antipsychotics, traditional antipsychotics, and selective serotonin reuptake inhibitors in treating pediatric aggression with the choice of medication dependent on symptomology. Despite increased support for pediatric psychotropic use, there is a need for more long-term safety and efficacy studies of existing medications and newer, safer, and more effective agents with fewer side effects for the pharmacological treatment of all childhood disorders in which aggression is prominent. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Responding to an identified need: A joint department of defense/department of veterans affairs training program in eye movement desensitization and reprocessing (EMDR) for clinicians providing trauma services.

An earlier study of federal Department of Defense mental health professionals found relatively few trained in the psychotherapies for posttraumatic stress disorder previously identified as effective by both this department and the federal Department of Veterans Affairs. In response to that need, a training program for one of the psychotherapies, eye movement desensitization and reprocessing (EMDR), was implemented utilizing personnel from these federal departments with assistance from a nonprofit agency. This article presents an evaluation of that program with rating data gathered from participants as well as treatment outcome data from the application of the training to patients. The program was highly rated by the participants and the impact of EMDR treatment was significant. Suggestions for similar programs and for further research are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Parent training for attention-deficit hyperactivity disorder: its impact on parent functioning

This study examined changes in parent functioning resulting from parental participation in a behavioral parent training (PT) program specifically designed for school-aged children with attention-deficit hyperactivity disorder (ADHD). Relative to wait list controls, subjects who completed the nine-session PT program showed significant posttreatment gains in both child and parent functioning, which were maintained 2 months after treatment. In particular, there were PT-induced reductions in parenting stress and increases in parenting self-esteem, which accompanied parent-reported improvements in the overall severity of their child's ADHD symptoms. In addition to their statistical importance, these findings are discussed in terms of their clinical significance, utilizing methods developed by Jacobson and Truax (1991).     

Language, communication, and transference in child analysis. I. Selective mutism: the medium is the message

Selective mutism is a psychiatric condition in which children stop speaking to all except their closest family members. Analytic material from a 4 1/2-year-old selectively mute child demonstrates how his symptom of mutism was embedded in a character structure in which not only verbal dialogue but play and other nonverbal communication were disrupted. Because communication was severely limited, I modified my analytic technique. Despite obstacles to communication, conflicts from different developmental levels were revived in the transference. Even in these difficult circumstances, analytic work in the transference resulted in significant change.     

Token reinforcements in the shaping of children's mealtime behaviour.

Shaping and subsequent extinction of acceptable mealtime behavior through selective token reinforcement was attempted with institutionalized, emotionally disturbed children. Results suggested the feasibility of utilizing individual judgements by staff personnel in behavior shaping and dispensing of reinforcements. In addition, control of mealtime behavior in some children was seen to vary as a function of the presentation or withholding of tokens. (PsycINFO Database Record (c) 2010 APA, all rights reserved)