Selective Mutism and Its Relations to Social Anxiety Disorder and Autism Spectrum Disorder

Platelet Levels of Brain-Derived Neurotrophic Factor in Adults with Autism Spectrum Disorder: Is There a Specific Association with Autism Spectrum Psychopathology?

To date, although several studies have investigated the circulating levels of brain-derived neurotrophic factor (BDNF) in children with autism spectrum disorder (ASD), only a few authors have addressed their evaluation in adults. Furthermore, an important limitation of these studies lies in the fact that circulating BDNF is stored in platelets and released into the circulation when needed. To the best of our knowledge, a very limited number of studies have related peripheral BDNF values to platelet counts, and yet no study has evaluated intra-platelet BDNF levels in adults with ASD. In this framework, the aim of the present work is to pave the way in this field and evaluate platelet BNDF levels in adult ASD patients, as well as their correlation with autistic symptoms and related psychopathological dimensions. We recruited 22 ASD and 22 healthy controls, evaluated with the Adult autism subthreshold spectrum (AdAS Spectrum), the Social Anxiety Spectrum-self report (SHY-SR), the Trauma and loss spectrum-self report (TALS-SR), the Work and Social Adjustment Scale (WSAS), and the Mood Spectrum-self report for suicidality. Intra-platelet BDNF levels were also assessed. The results highlighted lower BDNF levels in the ASD group; moreover, AdAS Spectrum and WSAS total score as well as AdAS Spectrum Restricted interest and rumination, WSAS Private leisure activities, TALS-SR Arousal, and SHY-SR Childhood domains were significant negative predictors of platelet BDNF levels.

Differential Diagnosis of Autism and Other Neurodevelopmental Disorders

This article discusses the diagnostic criteria for autism spectrum disorder (ASD), as well as other neurodevelopmental disorders that may be confused with or co-occur with ASD. Practitioners involved in diagnostic assessment of ASD must be well versed in the features that differentiate ASD from other conditions and be familiar with how co-occurring conditions may manifest in the context of ASD. ASD symptoms present differently across development, underscoring the need for training about typical developmental expectations for youth. Periodic reevaluations throughout development are also important because support needs for individuals with autism change over time.

Can We Be Creative with Communication? Assessing Decision-Making Capacity in an Adult with Selective Mutism

Selective mutism is an anxiety disorder in which an individual is unable to speak in certain social situations though may speak normally in other settings (Hua & Major, 2016). Selective mutism in adults is rare, though people with this condition might have other methods of communicating their needs outside of verbal communication. Healthcare professionals rely on a patient's ability to communicate to establish if they have decision-making capacity. This commentary responds to a case of a young adult patient with selective mutism and social anxieties that significantly limited his ability to communicate with anyone in the healthcare team. This required a creative, patient-centered approach to engage in meaningful communication.

Presence and correlates of autistic traits among patients with social anxiety disorder

Introduction

Due to their similar behavioral presentation, it can sometimes be challenging to distinguish between a social anxiety disorder (SAD) and the social avoidance that is frequently described in autism spectrum disorder (ASD). Moreover, a growing body of evidences is reporting that a significant proportion of subjects with ASD also meet the requirements for SAD and, vice versa, subjects with SAD tend to exhibit a higher prevalence of autistic traits.

Aim

In this framework, the current study aims to evaluate prevalence and correlates of autistic traits in a sample of adult subjects diagnosed with SAD and healthy controls (HC), also evaluating which autism spectrum dimensions may statistically predict higher SAD symptoms.

Methods

56 subjects with a clinical diagnosis of SAD and 56 gender and age matched HC were recruited from the Psychiatric Clinic of the University of Pisa. Subjects were assessed with the SCID-5, the Social Anxiety Spectrum - Short Version (SHY- SV) and the Adult Autism Subthreshold Spectrum (AdAS Spectrum).

Results

SAD group scored significantly higher in all AdAS Spectrum and SHY-SV domains and total score compared to the HC group with no significant gender difference. SHY-SV total and domain scores, were strongly and positively and strongly correlated with all AdAS Spectrum domains and total score. AdAS Spectrum total score and Childhood/Adolescence, Non-Verbal Communication, Empathy and Restricted interests and Rumination domain scores score were significant predictors of higher SHY-SV score.

Conclusion

Our results confirm the link between SAD and autistic traits also in adult population, describing not only high levels of autistic traits in SAD adults, but also significant correlations between many core features of the two disorders and a predictive role of autistic traits on higher SAD symptoms.

Selective mutism and the risk of mental and neurodevelopmental disorders among siblings

The siblings of children with mental disorders are more likely to experience mental health issues themselves, but there has been a lack of sibling studies on selective mutism (SM). The aim of this population-based study was to use national registers to examine associations between children with SM and diagnoses of various mental disorder in their siblings. All singleton children born in Finland from 1987 to 2009, and diagnosed with SM from 1998 to 2012, were identified from national health registers and matched with four controls by age and sex. Their biological siblings and parents were identified using national registries and the diagnostic information on the siblings of the subjects and controls was obtained. The final analyses comprised 658 children with SM and their 1661 siblings and 2092 controls with 4120 siblings. The analyses were conducted using generalized estimating equations. Mental disorders were more common among the siblings of the children with SM than among the siblings of the controls. The strongest associations were observed for childhood emotional disorders and autism spectrum disorders after the data were adjusted for covariates and comorbid diagnoses among SM subjects. The final model showed associations between SM and a wide range of disorders in siblings, with strongest associations with disorders that usually have their onset during childhood. Our finding showed that SM clustered with other mental disorders in siblings and this requires further research, especially the association between SM and autism spectrum disorders. Strong associations with childhood onset disorders may indicate shared etiologies.

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.

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.

Preliminary perceived intervention changes and engagement in an evidence-based program targeted at behavioral inhibition during early childhood, delivered in-person and online

Introduction

Behavioral inhibition during early childhood is one of the strongest risk factors for the development of later anxiety disorders. Recently developed in-person interventions that target both young children who are highly inhibited and their parents (e.g., the Turtle Program), have decreased children's anxiety and have increased social participation in the peer group. However, researchers have yet to examine the effects of intervention mode of delivery. In the present study, we compared the pre-to post-intervention changes in child and parenting functioning of families participating in the Turtle Program, delivered in-person and online with those changes made in families allocated to a waiting-list condition; compared session attendance, homework completion and satisfaction with the intervention outcomes of families involved in the Turtle Program, delivered in-person and online; and explored the predictive role of parenting and child factors in session attendance, homework completion and satisfaction with the outcomes of families involved in the Turtle Program, depending on the mode of delivery (in-person vs. online).

Method

Fifty-seven parents of highly inhibited preschoolers (3-5 years), with no diagnosis of selective mutism or developmental disorders, who were randomly allocated to waiting-list (n = 20), Turtle Program delivered in-person (n = 17) and online (n = 20) conditions completed the Portuguese versions of the Behavioral Inhibition Questionnaire, the Preschool Anxiety Scale, the Social Behavior and Competence Scale, the Modified Child-Rearing Practices Questionnaire at pre- and post-intervention assessment. Parents also completed the Preschool Shyness Study Satisfaction Survey at post-intervention assessment.

Results

Independent of intervention mode of delivery, generalized equation estimates revealed a reduction in children's total anxiety symptoms and an improvement in parental nurturing behaviors. Child anxiety and social competence at pre-assessment were the most prominent predictors of session attendance and satisfaction with post-intervention child and parenting outcomes.

Discussion

Overall, this study showed that parents in both intervention conditions perceived comparable positive changes in child functioning from pre- to post-intervention assessment and similar levels of session attendance, homework completion, and satisfaction. Significantly, however, perceived satisfaction with post-intervention child and parenting outcomes was higher, when children were reported to display higher SEL skills at baseline, independent of the intervention mode of delivery.

Symptoms of Selective Mutism in Middle Childhood: Psychopathological and Temperament Correlates in Non-clinical and Clinically Referred 6- to 12-year-old Children

The purpose of this study was to study psychopathological and temperamental correlates of selective mutism (SM) (symptoms) in a mixed sample of non-clinical (n = 127) and clinically referred (n = 42, of whom 25 displayed the selective non-speaking behavior that is prototypical for SM) 6- to 12-year-old children. Parents completed questionnaires to measure their child's symptom levels of selective mutism, social anxiety, autism spectrum disorder, and the temperament trait of behavioral inhibition. The results first and foremost showed that SM symptoms were clearly linked to social anxiety and an anxiety-prone temperament (behavioral inhibition), but findings also suggested that autism spectrum problems are involved in the selective non-speaking behavior of children. While the latter result should be interpreted with caution given the methodological shortcomings of this study, findings align well with the notion that SM is a heterogeneous psychiatric condition and that clinical assessment and treatment need to take this diversity into account.

School-based cognitive-behavioural therapy for children and adolescents with social anxiety disorder and social anxiety symptoms: A systematic review

BACKGROUND

Social anxiety disorder (SAD) is prevalent among children and adolescents. Cognitive-behavioural therapy (CBT) has been used as the first-line treatment. However, evaluation of CBT conducted in a school setting has been scarce.

OBJECTIVES

This study aims to review the CBT and its effectiveness in the school setting for children and adolescents with SAD or social anxiety symptoms. Quality assessment on individual studies was conducted.

METHODS

Studies were identified through the search in PsycINFO, ERIC, PubMed and Medline targeting CBT conducted in a school setting with an aim to treat children and adolescents with SAD or social anxiety symptoms. Randomised controlled trials and quasi-experimental studies were selected.

RESULTS

A total of 7 studies met the inclusion criteria. Five studies were randomised controlled trials, and two were quasi-experimental studies with 2558 participants aged 6-16 years from 138 primary schools and 20 secondary schools. There were minor effects to reduce social anxiety symptoms for children and adolescents at post-intervention in 86% of the selected studies. Friend for Life (FRIENDS), Super Skills for Life (SSL) and Skills for Academic and Social Success (SASS) conducted in school were more effective than the control conditions.

CONCLUSIONS

There is a lack of quality of the evidence for FRIENDS, SSL and SASS, due to inconsistencies on the outcome assessments, statistical analyses, and the fidelity measures adopted in individual studies. Insufficient school funding and workforce with relevant health background, and the low level of parental involvement in the intervention would be the major challenges in school-based CBT for children and adolescents with SAD or social anxiety symptoms.

Intervention with a humanoid robot avatar for individuals with social anxiety disorders comorbid with autism spectrum disorders

For some individuals with social anxiety disorders (SAD) comorbid with autism spectrum disorders (ASD), it is difficult to speak in front of others. Herein, we report the case of a patient with SAD comorbid with ASD who could not speak in front of others until she used a humanoid robot as her avatar. During the intervention, her personality changed from shy to outgoing, which is explained by the Proteus effect. These case findings suggest that interventions with a robot avatar might improve the motivation for individuals with SAD comorbid with ASD who cannot speak in front of others to communicate.

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.

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.

Challenges Surrounding the Diagnosis of Autism in Children

This comprehensive thematic review aims to highlight and familiarize readers with the challenges and pitfalls encountered in differential diagnosis of autism spectrum disorders (ASD) in children to facilitate the process of accurate identification by stakeholders. Accordingly, articles that best answer our questions and highlight our concerns were chosen from well-established publishers with prime peer reviewed journals. Included are studies showing alternate views of the issues so as to point readers to other possibilities. ASD, a complex dynamic biological-neurodevelopmental disorder, is underscored by its heterogeneous symptomology, severity, and phenotypes - all characterized by social communication deficits and presence of restricted interests and repetitive behaviours (RRBs), the core symptoms in ASD. Language and intellectual capacities do not form ASD core symptoms although vary considerably. Accurate identification is challenging as ASD is often enmeshed with other neurodevelopmental disorders, and medical comorbidities, a situation now recognized as the rule rather than the exception in child psychiatry and developmental medicine. ASD is a disorder with varying performance and severity of symptoms over time, including unexpected loss of early skills, and lost diagnosis in some children following treatment. The review reiterates the urgency in accurate diagnosis in face of the rapid rise in ASD prevalence globally, and risk-increase in delayed or denied treatment with undesirable life-long consequences for most of the affected children. In addition, a call for change is advised to circumvent the ethical dilemma posed by the present "deficit model" in ASD diagnosis. Here, ASD prevalence is presented first, followed by emphasis on importance of accurate early diagnosis, and challenges in its accomplishment due to flaws in diagnostic instruments and other contributing factors. Next follow the required criteria for accurate identification, and its difficulties attributed to comorbid conditions, gender differences, and socio-economic and cultural influences. The conclusion includes future directions and a take away message.