Frozen with Fear? Attentional Mechanisms in Children with Selective Mutism

Symptoms of selective mutism beyond failure to speak in children and adolescents

Understanding the symptoms of a mental disorder is essential for accurate diagnosis or selecting appropriate treatment targets. Despite this, there is a surprising lack of systematic research on the symptoms of selective mutism (SM). While the DSM-5 defines failure to speak as the only core symptom of SM, sparse research suggests that children with SM may experience additional symptoms. Previous studies have been limited in their identification of symptoms of SM, either by using a predefined set of symptoms or by only asking for anxiety-specific symptoms. This may have resulted in important symptoms being overlooked. In this study, we provided n = 86 parents of children and adolescents with SM (3-18 years) with a symptom definition appropriate for the target group. Additionally, parents were asked an open-ended question about any other symptoms they had observed in their children, beyond the failure to speak. The symptoms reported were categorized using qualitative content analysis (QCA) and examined for frequency and association with symptom severity. Ten different symptom categories were identified, with fear, freezing, and avoidance/security behaviors being the most prevalent. On average, parents reported M = 4.74 (SD = 2.37) symptoms from different symptom categories. Only fear was found to be related to symptom severity of SM. As the findings suggest that SM encompasses various symptoms beyond failure to speak, a more sophisticated understanding of SM as a mental disorder with multiple symptoms seems essential. The clinical implications of this are discussed in further detail.

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.