Selective Mutism: Identification of Subtypes and the Influence of Treatment

1. Selective Mutism: Identification of Subtypes and the Influence of Treatment Christy Mulligan, Psy.D Long Island University 2011 Annual NASP Convention Mini-Skills Workshop

2. Why Investigate if there are Subtypes of SM • Knowledge of the potential existence of specific subtypes of SM will increase school psychologist’s and other professionals understanding of different treatment options that they may not have previously considered. • Children who are treated specifically for their individual subtype will make greater treatment gains than those who are treated more generally. • Children who are treatment resistant may suffer from a more genetically based severe continuum of SM.

3. Implications in School • SM can cause social, behavioral, and academic problems • Occurs in all cultures, social classes, and nationalities • Prevalence rate • .2-.71% school-age children • Afflicts more girls than boys • Often remits by adulthood, with presentations of social phobia/avoidance • Need for Effective classroom-based interventions • Need to identify if different subtypes exist • Need to distinguish different treatment options for SM children with atypical presentations

4. Purpose of the Study • Exhaust the literature in support of different subtypes of SM • Distinguish if specific subtypes of SM exist • Explore unique factors that distinguish each SM subtype • Link best practice treatment options to specific subtypes of SM • Gain a better understanding of comorbid disorders that may be common to specific subtypes of SM

5. Research Questions • What does the literature say about the causes of, or factors associated with, SM and possible subtypes of SM?

6. DSM-IV-TR Criteria • DSM-IV-TR • Other disorders of infancy, childhood, or adolescence • Characteristics • The persistent failure to speak in specific social situations where speaking is expected, despite speaking in other situations. • SM often interferes with educational or occupational achievement or with social communication; and it must last for at least 1 month, but not limited to the first month of school. • SM should not be diagnosed if the child’s failure to speak is due solely to a lack of knowledge, or discomfort with the spoken language required in a social situation. • It is also not diagnosed if the disturbance is better accounted for by embarrassment related to having a Communication Disorder, or if it occurs exclusively in the presence of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder. • Instead of communicating by standard verbalization, children with this disorder may communicate by gestures, nodding, or shaking the head, or pulling or pushing, or, in some cases, by monosyllabic, short, or monotone utterances, or in an altered voice.

7. Comorbities • Comorbidities Associated with SM • Social Anxiety • Speech and language delays • Elimination disorders • Motor delays • Sensory integration disorder • Oppositional behavior

8. Etiology • Etiology • Etiology is not well understood (Krysanski, 2003) • Genetic Predisposition • Anxiety • Social Anxiety • Psychopathology • Neurodevelopmental vulnerabilities • Temperament • Behavioral Inhibition • Environmental Factors • Family stress • Instability

9. Theory Based Explanations • Theoretical Explanations of SM • Psychodynamic theorists believe SM is a manifestation of unresolved conflict (Dow et al., 1995). • The family dynamics/systems perspective believes children with SM are involved in faulty family relationships that lead the mutism symptoms (Anstendig, 1998). • Behavioral theorists see SM as the product of a long series of negatively reinforced learning patterns (Leonard & Topol, 1993). • Cognitive behavioral theorists see SM in relation to anxiety disorders (Cohen, et al., 2006).

10. Proposed Subtypes • Anxiety/Social Anxiety • Expressive Language • Oppositional • ELL • Sensory/Self Regulation

11. Methodology • Participants • Children age 3-18 who all meet criteria for SM • International data base provided by SMart Center, Jenkintown, PA • Middle –Upper Middle class SES

12. Methodology (cont.) • Overview of Research Design • Use of archived data • All participants data was coded with a number so that all participant information was kept anonymous • Only children between the ages of 3-18 with a diagnosis and symptoms of SM were used in this study • Children were excluded if they also carried a diagnosis of autism or PDD-NOS • All relevant data needed to be completed

13. Methodology (cont.) • Instrumentation • Selective Mutism Comprehensive Diagnostic Questionnaire (Shipon-Blum, 2004) • Designed to collect information about a child with SM, including an in depth developmental history, medical history, educational history and a symptom severity section. • List of items at the end of the SM-CDQ that parents were asked to rate on a scale of 1-10. • Mutism Behavior Rating Scale • Grouped items into categories

14. Basic Demographic Characteristics of Sample Table 1 Basic Demographic Characteristics of Sample ______________________________________________________________________________________ Variablen Percent ______________________________________________________________________________________ Gender Males 63 34% Females 123 66% Grade Pre-K 52 28% Elementary School 111 60% Middle School 13 7% High School 7 4% Self-Identified Race African-American 3 1.6% Asian-American 7 3.8% Caucasian-American 143 77% Latino-American 9 4.8% Biracial 22 12% ______________________________________________________________________________________

15. Methodology (cont.) • Measures (cont.) • SM-CDQ • Characteristics Mutism (CM) variables (n= 72) • Descriptive (D) variables (n= 70) • Mutism Behaviors Rating Scale (MBRS) variables (n= 61) • Ratings from 1-10

16. Methodology (cont.) • Analysis of Data • Statistical Analysis • Demographic and Descriptive data were computed for frequency information and calculation of measures of central tendency • Independent variables: CM variables & subtypes characteristics • Dependent variables: MBRS subscales

17. Methodology (cont.) • Statistical Analysis (cont.) • ANOVA was used to compare the MBRS subscales as dependent variables • Bonferroni and Least Significant Difference (LSD) post hoc tests were utilized for multiple comparisons • Only subtypes that had ten or more participants were included, and they were compared on the descriptive and MBRS variables to guard against Type I error

18. Results: Participant Characteristics on Demographic & Descriptive Variables by SM subtypes Table 3 Participant Characteristics on Demographic & Descriptive Variables by SM subtypes ___________________________________________________________________________ Cluster ___________________________________________________________________________ G A/L LF S/P E/B __________________________________________________________________________ _ n 71 15 23 22 11 Gender (%) Female 66 67 52 50 91 Male 24 33 48 50 9 Grade (%) Pre-K 41 20 48 9 27 Elementary 48 73 52 82 73 Middle .07 7 0 9 0 High .03 0 0 0 0 ___________________________________________________________________________

20. Results: Parent’s Mutism Characteristics by Subtype Table 4 Parent’s Mutism Characteristics by Subtype ___________________________________________________________________________ Subtype Variable G A/L LF S/P E/B ___________________________________________________________________________ n 71 15 23 22 11 Maternal Shy (%) Yes 75 60 74 64 82 No 25 40 26 23 18 Maternal Mute as Child (%) Yes 7 0 17 14 0 No 92 100 83 82 100 Maternal Anxiety (%) Yes 37 40 52 50 55 No 62 60 48 49 45 ___________________________________________________________________________

21. Results: Parents Mutism Characteristics by Subtype (cont.) Table 4 (continued) __________________________________________________________________________ Subtype Variable G A/L LF S/P E/B __________________________________________________________________________ n Maternal Depression Yes 16 0 39 32 36 No 82 100 61 64 64 Paternal Shy Yes 66 47 52 50 36 No 34 53 48 50 64 Paternal Mute as Child Yes 7 0 4 5 9 No 92 100 91 77 90 ___________________________________________________________________________

22. Results: Parents Mutism Characteristics by Subtype (cont.) Table 4 (continued) ___________________________________________________________________________ Subtype Variable G A/L LF S/P E/B ___________________________________________________________________________ Paternal Anxiety Yes 24 27 35 36 27 No 76 73 57 50 73 Paternal Depression Yes 9 13 9 32 9 No 92 87 83 55 91 ___________________________________________________________________________ Note.G = Global; A/L = Anxiety/Language; LF = Low Functioning; S/P = Sensory Pathology; E/B = Emotional/Behavioral.

23. SM Subtype Results • Global Mutism (G) • (n = 71) • Less impaired as compared to the other subtypes • Generally academically capable • No exhibit sensory, emotional and behavior problems

24. SM Subtype Results (cont.) • G Mutism (cont.) • G has a 2:1 gender ratio in favor of females • Encompasses all racial variables • May be the most common subtype

25. SM Subtype Results (cont.) • Anxiety/Language Mutism (A/L) • Significantly higher mean score as compared to the other groups for Anxiety based on LSD post hocs • Lability and Academic Success were also problematic • Largest percent of a comorbid anxiety disorder

26. SM Subtype Results (cont.) • A/L Mutism (cont.) • Largest percent of trauma exposure • Did not meet S & L milestones on time • Largest percent of speech impediments • Most speech and language diagnoses • 2:1 gender ratio in favor of females

27. SM Subtype Results (cont.) • Low Functioning Mutism (LF) • This LF subtype had an even gender ratio • No significant comoribid psychiatric disorders • Maternal mutism and depression were elevated as compared to the other subtypes

28. SM Subtype Results (cont.) • LF Mutism (cont.) • The Positive Academic Success scale was statistically significant on Bonferroni post hocs • Statistically significant sensory and executive problems as well as lability according to LSD post • Highest percent of children with SM in special education

29. SM Subtype Results (cont.) • Sensory/Pathology Mutism (S/P) • Sensory subscale earned the highest mean and was statistically significant from the other subtypes according to Bonferroni post hoc analysis • Largest percent of SM children with a comorbid diagnosis of Disorder of Sensory Integration • Significant mean scores on the Oppositional and Lability subscales

30. SM Subtype Results (cont.) • S/P Mutism (cont.) • Most racially diverse, and has a high rate of bilingual children • Largest number of children with separation anxiety problems • Largest number of children with delays in motor skills

31. SM Subtype Results (cont.) • S/P Mutism (cont.) • Most impaired subtype in comparison to the other subtypes • Comorbid diagnoses of learning disabilities, ADHD, ODD, and Depression • May be the most difficult subtype to treat

32. SM Subtype Results (cont.) • Emotional/Behavioral (E/B) • Highest mean scores for all subtypes in the areas of Executive, Oppositional, and Labile; significant according to Bonferroni and LSD post hocs • Second highest mean score for Sensory • 10:1 gender ratio, in favor of females • No significant academic problems

33. Subtype Differentiation/Clinical Implications • E/B subtype no significant academic problems • Possible inaccurate parent rating their children on the MBRS • Environmental cognitive and/or behavioral factors are indeed maintaining (Mulligan & Christner, 2006) and conditioning SM (Shipon-Blum, 2010). • Highest rate of maternal shyness, maternal anxiety and fathers of children with SM who were mute when they were children • Further exploration into environmental and/or genetic factors is warranted.

34. Subtype Differentiation/Clinical Implications • E/B subtype afflicts more preschool, female youngsters • May imply newly discovered disorder • Young children will typically shut down more often than older children (Shipon-Blum, 2010). • Many young children with SM may demonstrate oppositional and labile behaviors.

35. Subtype Differentiation/Clinical Implications (cont.) • In the S/P subtype, children appear to experience the most pathology • Comborid diagnoses include LD, ADHD, ODD, and Depression • Consistent with literature findings that children with SM may have an associated developmental delay or learning problems nearly as often as an anxiety disorder (Cleater & Hand, 2001; Kolvin & Fundudis, 1981). • ADHD and ODD were one to ten times greater in the SM population (Ford, et al., 1998).

36. Subtype Differentiation/Clinical Implications (cont.) • Highest percentage of both paternal anxiety and depression • Paternal psychopathology could negatively impact children with SM, who are already vulnerable for psychopathology themselves • Important to address the needs of family members as well as the child with SM

37. Subtype Differentiation/Clinical Implications (cont.) • A/L Subtype experienced • Early S & L delays • Speech impediments • Highest number of children receiving S & L services • Highest percent of children in comparison to the other subtypes with a comorbid anxiety disorder.

38. Subtype Differentiation/Clinical Implications (cont.) • A/L subtype (continued) • Total percent of children with SM in this study with a comorbid anxiety disorder was only 29%, well under what is often reported in the literature with some studies reporting rates as high as 74% (Kristensen, 2000). • Not all children with SM are anxious, which could be a differentiation • Highest mean score for Anxiety, which could exacerbate their language difficulties • Lowest percentage of parents reporting their own anxiety problems

39. Subtype Differentiation/Clinical Implications (cont.) • A/L subtype (continued) • Children with SM in this subtype were reported to have the highest percent of trauma exposure compared to the other subtypes, • Could be the source of their anxiety • Implies there may be strong environmental variables • Genetic family history of anxiety may play less of a role in relation to some children with SM (Dummit et al., 1997; Kristensen, 2000).

40. Subtype Differentiation/Clinical Implications (cont.) • LF mutism subtype had greater academic problems as compared to the other subtypes • Higher levels of both Sensory and Executive problems • Largest percentage of IEP’s • Largest percentage of mothers who were mute as children and had maternal depression • This could be a factor in the low functioning children in this subtype, if the mother is not engaged, attends regular school functions, or will advocate for their child.

41. Subtype Differentiation/Clinical Implications (cont.) • Global (G) mutism subtype has the largest group (n = 71). • This profile may be more typical • Problems with flexibility • Least impaired in comparison to the other subtypes in most areas. • May have elevated levels of anxiety but not pervasive in all or even most environments, but rather in social performance situations. • May primarily have deficits in social anxiety and communication.

42. Subtype Differentiation/Clinical Implications (cont.) • Not all children with SM are severely anxious, have speech and language problems, are low academically, or experience sensory emotional/behavioral problems. • This study supports that although there are many secondary factors that contribute to each subtype, there are indeed distinctions, and characteristics absent in other subtypes.

43. Treatment implications • An additional aim of this study was to look at the parents of children with SM in respect to their own endorsement of having SM when they were children. • It was hypothesized that if their offspring developed SM, it would be a more severe and treatment resistant form of SM. • LF subtype – highest percentage of mother mute as children. • E/B subtype - highest percentage of fathers who were mute as children.

44. Treatment Implications (cont.) • These two subtypes may demonstrate the greatest mix of symptomatology • May suggest a more difficult to treat form of SM. • This does not mean that these two subtypes have more severe forms of SM, rather, treatment strategies may include multiple facets due to the complexity of the symptoms.

45. Treatment Implications (cont.) • G subtype, several different modalities may be successful, or different techniques of one modality. • Benefit from social skills training, learning to be more flexible, and boosting self-esteem, education about SM may also be beneficial for this subtype • A/L subtype, a combination of CBT therapy and language therapy may be successful

46. Treatment Implications (cont.) • The LF subtype may benefit from multiple intervention strategies, both related to their SM and other areas • Family work and targeted academic interventions may be required or they may need specially designed instruction to meet their academic needs within the school

47. Treatment Implications (cont.) • S/P subtype may need to utilize different strategies before one is successful. • An ecological evaluation, exploring what environmental factors are maintaining the symptoms of SM. • Potentially if several strategies fail, this subtype may benefit from an adjunctive pharmacotherapy approach. • E/B subtype treatment may focus on behavioral management strategies. Recognizing the functional determinants for the overt behaviors this SM subtype displays

48. Limitations • Archived Data – selection bias due to this sample of convenience • Instruments – SM-CDQ may not demonstrate adequate validity and reliability which may result in threats to statistical conclusion validity • Socio-economic status of the participants could influence some of the proposed ELL subtype, because typically immigrants new to the US do not have the educational or financial resources to seek treatment of this nature

49. Limitations (cont.) • Generalizability also limited to middle and upper middle class families, and parents with higher education level • The data consisted of parent report only, and there was no control group to compare ratings on the MBRS, so normative comparisons and inter-rater reliability were not possible. • The archived data did not provide an adequate sample of non-English speaking immigrant families who had children with SM, therefore, the proposed ELL subtype did not emerge

50. Limitations (cont.) • The higher percentage of females within the subtypes may have factored into the results obtained and these results may not generalize to a strictly male population. • Many of the subtypes had a small sample size, just marginally making the cutoff n =10 for a subtype, this also decreases the likelihood that results have external validity. • This study utilized behavior rating scales that have not been externally validated at this time.