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

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.

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.

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.

Silence and related symptoms in children and adolescents: a network approach to selective mutism

Background

Silence in certain situations represents the core symptom of selective mutism (SM). However, it is unclear what additional symptoms are part of this disorder. Although knowledge of symptoms is essential for diagnostics and intervention, to date, only scarce research exists on circumscribed symptoms of SM. Given the large overlap between SM and social anxiety disorder (SAD), it remains also unclear which symptoms can differentiate both disorders.

Methods

A network analysis of potential symptoms of SM was performed based on a mixed sample of N = 899 children and adolescents with and without indication of SM (n = 629 with silence in certain situations). In a preliminary analysis, we demonstrated that children with and without silence in certain situations do not differ with respect to their network structure, justifying an analysis on the entire mixed sample. Possible communities (symptom clusters) within the network and thus potential latent variables were examined, and symptoms were analyzed in terms of their centrality (the extent to which they are associated with other symptoms in the network). To investigate the differentiability of symptoms of the SM network from symptoms of SAD, we computed a network that additionally contains symptoms of SAD.

Results

In the resulting network on symptoms of SM, silence was, as expected, the symptom with the highest centrality. We identified two communities (symptom cluster): (1) symptoms associated with the fear response of freezing, (2) symptoms associated with speech production and avoidance. SM network symptoms and SAD symptoms largely formed two separate symptom clusters, with only selectivity of speaking behavior (more talkative at home and taciturn or mute outside the home) falling into a common cluster with SAD symptoms.

Conclusions

Silence appears to have been confirmed by analysis as a core symptom of SM. Additional anxiety-related symptoms, such as avoidance behavior or motor inhibition associated with freezing, seem to co-occur with silence. The two communities of SM potentially indicate different mechanisms of silence. The symptoms of SM appear to be distinguishable from those of SAD, although there seems to be overlap in terms of difficulty speaking in situations outside the home.

Frozen with Fear? Attentional Mechanisms in Children with Selective Mutism

Background

Children with selective mutism (SM) are consistently unable to speak in certain social situations. Due to an overlap between SM and social anxiety disorder (SAD) in children, similar mechanisms could apply to both disorders. Especially biased attentional processing of threat and fear-induced reduced visual exploration (referred to as attentive freezing) appear promising in SM.

Methods

A total of N = 84 children (8–12 years, SM: n = 28, SAD: n = 28, typical development (TD): n = 28) participated in an eye-tracking paradigm with videos of a social counterpart expressing a question, a social evaluation or a neutral statement. We investigated gaze behavior towards the social counterpart’s eye-region and the extent of visual exploration (length of scanpath), across conditions.

Results

There were no group differences regarding gaze behavior on the eye region. Neither gaze behavior with respect to the eye region nor visual exploration were dependent on the video condition. Compared to children with TD, children with SM generally showed less visual exploration, however children with SAD did not.

Conclusion

Reduced visual exploration might be due to the mechanism of attentive freezing, which could be part of an extensive fear response in SM that might also affect speech-production. Interventions that counteract the state of freezing could be promising for the therapy of SM.

Psychophysiological mechanisms underlying the failure to speak: a comparison between children with selective mutism and social anxiety disorder on autonomic arousal

BACKGROUND

Selective mutism (SM) has been conceptualized as an extreme variant of social anxiety disorder (SAD), in which the failure to speak functions as an avoidance mechanism leading to a reduction of intense fear arousal. However, psychophysiological studies in children with SM are scarce and physiological mechanisms underlying the failure to speak are largely unknown. In contrast, children with SAD are characterized by a combination of a chronically elevated physiological arousal and a blunted physiological fear response to social stress. Due to the large overlap between SM and SAD, similar mechanisms might apply to both disorders, while differences might explain why children with SM fail to speak. The aim of our study is to investigate psychophysiological mechanisms of the failure to speak in children with SM.

METHODS

We assessed in a total of N = 96 children [8-12 years, SM: n = 31, SAD: n = 32, typical development (TD): n = 33] resting baseline arousal in absence of social threat and the course of physiological fear response in two social stress paradigms, differing in terms of whether the children are expected to speak (verbal task) or not (nonverbal task).

RESULTS

Children with SM were characterized by increased tonic arousal compared to the other two groups, and by a more inflexible stress response in the nonverbal but not in the verbal task compared to TD-children. Further analyses revealed that children with SM who did not speak during the verbal task already demonstrated reduced arousal in anticipation of the verbal task.

CONCLUSION

The increased tonic arousal generalized to non-social situations in SM could indicate a long-term alteration of the autonomic nervous system. Furthermore, the differential physiological stress response may indicate that silence acts as a maladaptive compensatory mechanism reducing stress in verbal social situations, which does not function in nonverbal situations. Our findings support the idea that the failure to speak might function as an avoidance mechanism, which is already active in anticipation of a verbal situation. Treatment of SM should take into account that children with SM may suffer from chronically elevated stress levels and that different mechanisms might operate in verbal and nonverbal social situations.

The Heterogeneity of Selective Mutism: A Primer for a More Refined Approach

Selective mutism is a persistent and debilitating psychiatric disorder in which a child fails to speak in situations where speaking is expected. Although listed as an anxiety disorder, the multifaceted and heterogeneous nature of selective mutism indicates that a more accurate conceptualization may be as a neurodevelopmental disorder. This article serves as a primer of historical and clinical presentations, empirical clinical profiles, clinical distinctions, assessment, and treatment related to the complexity of selective mutism. The article includes a brief discussion of selective mutism within a developmental psychopathology perspective with an eye toward reformed efforts for prevention, assessment, and treatment regarding this population.

Symptoms of Selective Mutism in Non-clinical 3- to 6-Year-Old Children: Relations With Social Anxiety, Autistic Features, and Behavioral Inhibition

Selective mutism (SM) is a psychiatric condition that is characterized by a failure to speak in specific social situations (e. g., at school) despite speaking normally in other situations (e.g., at home). There is abundant evidence that anxiety, and social anxiety in particular, is a prominent feature of SM, which is the main reason why this condition is currently classified as an anxiety disorder. Meanwhile, there is increasing support for the notion that autism-related problems are also involved in SM. The present study examined the relations between SM and social anxiety, autistic features, and behavioral inhibition to the unfamiliar (i.e., the tendency to react with restraint and withdrawal when confronted with unfamiliar stimuli and situations). Parents of 172 3- to 6-year-old preschool children completed an online survey for measuring the relevant constructs. Results showed that there were positive and statistically significant correlations between SM and social anxiety, autistic features, and behavioral inhibition. Regression analyses revealed that (1) both social anxiety and autistic features accounted for a significant and unique proportion of the variance in SM scores, and (2) that both of these variables no longer made a significant contribution once behavioral inhibition was added to the model. It can be concluded that while the involvement of social anxiety is unambiguous in SM, autism-related problems are also implicated. Furthermore, behavioral inhibition seems to play a key role in the non-speaking behavior of non-clinical young children.

Current Challenges in the Diagnosis and Management of Selective Mutism in Children

Selective mutism (SM) is a childhood disorder characterized by a consistent failure to speak in specific social situations (eg, school) despite speaking normally in other settings (eg, at home). This article summarizes evidence supporting the recent classification of SM as an anxiety disorder and discusses the implications of this re-classification for the assessment and treatment of SM in clinical practice. Meanwhile, clinicians should also realize that SM sometimes is a heterogeneous disorder in which other problems are also present that complicate the management of children with SM. As examples, we discuss speech and language problems, developmental delay, and autism spectrum disorders.