Understanding Selective Mutism

1. Understanding Selective Mutism Courtney keeton, phd Clinical psychologist Assistant professor of psychiatry The johns hopkins university school of medicine DECEMBER 3 2012

2. Questions Addressed • Is selective mutism (SM) the same as shyness? • Does SM go away over time, or is treatment needed? • What are behavioral treatments for SM? • What is the role of the school in SM treatment? • When should medication be considered? • How do I effectively parent my child with SM? C Keeton PhD

3. What Is Selective Mutism (SM)? • The consistent failure to speak in social situations when speaking is expected • Fluid speech in other situations (usually home & familiar settings) • Interferes with academic & social development • Duration: at least one month (not September!) • Not due to lack of knowledge/comfort with the language • Not better accounted for by communication or developmental disorder, or psychosis C Keeton PhD

4. Diagnostic Classification • DSM-IV-TR (2000) • Selective Mutism • DSM-5 (May 2013) • Social Anxiety Disorder (Selective Mutism) C Keeton PhD

5. Clinical Presentation • Large individual variation in communication behaviors • Context: school, home, public • People: peers, adults, family, strangers • Nonverbal Features: gestures, nods, eye contact • Verbal Features: volume, quantity, spontaneity C Keeton PhD

6. Epidemiology • 1 out of 140 kids (0.7%) • Comparable to other anxiety disorders such as OCD • Gender difference: mixed data • Preschool age of onset: before age 5 • Referrals typically made between 6.5 and 9 years of age C Keeton PhD

7. Course • MYTH: Child will “outgrow it” • Chronic • 1/3 remission • 1/3 remarkably improved • 1/3 minimal improvement • Risk for future impairment • Social Anxiety Disorder • Social skills deficits • Mood problems C Keeton PhD

8. Etiology • Familial/Genetic component • Family history of SM, shyness, anxiety • Temperament • Behavioral inhibition • Environmental vulnerability • Less socially active family • Autonomy-limiting parenting • Negatively reinforced behavior • MYTH: trauma → SM • Insidious onset C Keeton PhD

9. Other Common Concerns • Other forms of anxiety • Social phobia (>80%) • Separation anxiety (~30%) • Specific phobia (~15%) • Generalized anxiety disorder (~15%) • Physical symptoms • Elimination problems (~30%) • Constipation • Enuresis • Encopresis • Oppositional behavior • Communication disorders C Keeton PhD

10. Assessment • Observational methods • Interviewing • Pencil-and-paper questionnaires • Speech and language assessment C Keeton PhD

11. Treatment • Psychosocial Treatment • Pharmacological Treatment • Goals • Reduce anxiety • Increase quality and quantity of speech across people and situations • Achieve remission: spontaneous, age appropriate conversational speech across contexts C Keeton PhD

12. Psychosocial Treatment Approaches • First-line treatment = behavioral and cognitive-behavioral approaches Cognitive Behavioral Therapy C Keeton PhD

13. Basis of Psychological Problems Interpersonal and environmental contexts C Keeton PhD

14. Features of CBT • Time-limited • Skill-based, problem-specific, goal-oriented • Structured (but flexible) • Present and solution-focused • Collaborative • Empirically-based (data shows it works!) C Keeton PhD

15. CBT for SM C Keeton PhD

16. CBT for SM C Keeton PhD

17. Targeting Avoidant Behavior • Techniques: Graduated Exposure, Shaping, Stimulus Fading Read short story aloud Ask questions during “Guess Who” Whisper counting during “Chutes & Ladders” Mouth the names of pictures/colors during game Show home video of self talking to doctor C Keeton PhD

18. Targeting Accommodation by Others • Reduce “mind-reading” in low stress situations • Allow child a chance to respond before repeating a question • Create opportunities for speech • Stay involved in social activities (swimming, birthday parties) C Keeton PhD

19. Targeting Parenting Behaviors • Create structure/routine • Encourage independence in child • Offer praise/rewards for positive behaviors • Increase child’s control during play by narrating C Keeton PhD

20. Intervening at School Level • Collect teacher feedback • Provide education • Secure services through an Individualized Education Plan (IEP) or Section 504 Plan if appropriate • Enlist teacher help in defining and measuring daily speech goals • Consider use of daily report card C Keeton PhD

21. Sample Daily Report Card (Advanced) C Keeton PhD

22. Pharmacologic Treatment • Recommended when psychosocial interventions are ineffective or when symptoms are chronic and severe • First-line treatment = Selective Serotonin Reuptake Inhibitors • Fluoxetine (most studied) • Sertraline • Paroxetine C Keeton PhD

23. Conclusions • Is SM just shyness? • A formal diagnosis suggests a problem that has been ongoing, present in numerous situations, and causing impairment • My child has SM. Is treatment needed? • The majority of cases don’t resolve without intervention. In cases when SM “goes away,” there is high risk that anxiety persists. C Keeton PhD

24. Conclusions • Why are behavioral interventions recommended? • SM is maintained by avoidant behavior, and data suggests that SM can be effectively treated by learning healthy coping and approach behaviors in a gradual way. • Does the school need to be involved? • School is typically where the symptoms are most severe, so interventions need to be applied in the school. Treatment is most successful when school personnel are aware of the problem and part of the treatment collaboration. C Keeton PhD

25. Conclusions • When should medication be considered? • Data suggests that SSRIs are well-tolerated and effective in pediatric populations. These medications should be considered in treatment resistant cases, when symptoms are severe, or when additional anxiety or other problems exist. • How to I effectively parent my child with SM? • Be his/her biggest advocate. Understand that SM is not a voluntary phenomenon, and that progress is gradual. Collaborate with your child to make a plan. Praise brave speech and independent behavior. C Keeton PhD

26. Courtney Keeton, PhD The Johns Hopkins University School of Medicine Department of Psychiatry Division of Child & Adolescent Psychiatry Phone: 410-614-5174 Email: ckeeton@jhmi.edu C Keeton PhD