Intensive group behavioral treatment (IGBT) for children with selective mutism: A preliminary randomized clinical trial

Examining the Effectiveness of an Intensive Telemental Health Treatment for Pediatric Anxiety and OCD During the COVID-19 Pandemic and Pediatric Mental Health Crisis

Despite research supporting the efficacy of weekly outpatient videoconferencing-based cognitive behavioral therapy (VCBT), limited evidence exists about the benefits of leveraging VCBT for brief intensive formats. We examined the effectiveness of an intensive outpatient VCBT targeting pediatric anxiety and OCD. Quasi-experimental design was used to compare outcomes of intensive, in-person, group-based cognitive-behavioral therapy with medication management and caregiver guidance pre-pandemic, to a similar VCBT peri-pandemic (n = 130). Pretreatment and posttreatment assessments included patient- and caregiver-report of anxiety and functional impairment. Analyses of covariance were conducted, examining changes in anxiety and impairment between treatment groups, controlling for admission levels. No significant differences in posttreatment anxiety or impairment were observed between conditions. This study illustrates that intensive, group-based treatment for pediatric anxiety and OCD using VCBT is associated with comparable reductions in anxiety and impairment. It marks a crucial step toward providing broader access to quality care for youth in need.

Exposure-Based Online Intervention and Behavioral Parent Training for a Child with Selective Mutism: A Case Report

Although exposure-based practices are effective in treating selective mutism, difficulties arise when the child refuses to visit a clinical center. In this situation, it is important to intervene using remote technology and to support parents who have children with selective mutism. In this patient report, an exposure-based intervention using online technology was implemented for an 8-year-old girl with selective mutism. In addition, her mother was also experiencing increased parenting stress. Therefore, the mother received behavioral parent training specifically designed for parents of children with selective mutism. As a result, the child's nervousness decreased during the intervention, and the frequency of their speech, facial expression, and body motion improved. Initially, the child refused to visit our clinical center. However, they eventually agreed and managed to communicate non-verbally with the primary author in our clinical center. Behavioral parent training for selective mutism improved her mother's understanding of the condition, the way she interacts with her child, and reduced her parenting stress. Implementing Internet-based interventions is highly beneficial because it significantly reduces the fear of clinic or hospital visits among children with selective mutism. Furthermore, behavioral parent training tailored to selective mutism to improve parental stress and interaction can be a valuable support option for parents of children with selective mutism.

Phasic Versus Tonic Irritability and Associations with Family Accommodation Among Youth with Selective Mutism: A Latent Profile Analysis

Clinical presentations of selective mutism (SM) vary widely across affected youth. Although studies have explored general externalizing problems in youth with SM, research has not specifically examined patterns of irritability. Relatedly, research has not considered how affected families differentially accommodate the anxiety of youth with SM as a function of the child's temper outbursts (i.e., phasic irritability) and general angry mood (i.e., tonic irritability). Data were drawn from a sample of treatment-seeking children and adolescents with a primary diagnosis of selective mutism (N = 152; Mean age = 6.12 years; 67.11% female), and their caregivers. Latent profile analysis (LPA) was used to identify distinct profiles in SM youth that were characterized by varying levels of phasic and/or tonic irritability. Analyses further examined whether these different profiles were associated with different levels of family accommodation and global impairment. LPA identified 5 profiles: SM with No irritability, SM with Low Phasic Irritability, SM with High Phasic Irritability, SM with High Phasic and Moderate Tonic Irritability, and SM with High Phasic and High Tonic Irritability. Patterns of family accommodation and global impairment were highest among youth belonging to profiles characterized by high phasic irritability. Findings highlight separable patterns of irritability across youth with SM, with phasic irritability (i.e., temper outbursts) appearing particularly linked with increased family accommodation and overall global impairment. Assessing phasic irritability is critical for optimizing treatment in youth with SM and can be useful for flagging possible patterns of family accommodation contributing to overall impairment.

Implementation and Preliminary Outcomes of an Exposure-Based Summer Camp for Pediatric OCD and Anxiety

Despite the high prevalence of anxiety disorders in children and adolescents and the existence of effective evidence-based treatments for them, access to psychological care remains a major public health concern. Summer camps may provide an effective treatment avenue for youth who might not otherwise have access to care. This study describes the design and implementation of Fear Facers, a semistructured, 5-day, daytime exposure-therapy-based summer camp designed for youth with a primary diagnosis of obsessive-compulsive disorder (OCD), social anxiety, separation anxiety, or a specific phobia. Preliminary data regarding feasibility and patient outcomes is also reported. Among 52 children and adolescents aged 7 to 16 who attended one of six camp sessions between 2018 and 2021, significant reductions in anxiety (d = 0.54) and OCD symptoms (d = 0.57) were observed from pre-camp to immediately post-camp. A subset of campers who were followed for an additional 3 months post-camp (n = 22) showed maintenance of treatment gains. Retention rates for the intervention were high. Our investigation provides further support for the use of a camp-based design for cognitive-behavioral approaches, and may provide a unique setting to maximize elements of inhibitory learning in exposures. We also discuss a number of elements regarding feasibility that need consideration for those hoping to develop similar interventions.

Selective mutism in immigrant families: An ecocultural perspective

Although the diagnosis of selective mutism (SM) is more prevalent among immigrant children, the link between the disorder and an immigration background has been elusive. Guided by ecocultural models of development, the current study aimed to construct a theory-based description of SM while considering individual, family, and contextual risk factors. Participants were 78 children with SM (38.4% with an immigration background), and 247 typically developed children (18.2% with an immigration background). Consistent with previous studies, our results suggest that anxiety was the most important predictor of SM symptoms, above and beyond immigration background. Immigration, especially if coupled with bilingual status and low family income, predicted increased levels of SM symptoms. Identifying multi-level predictors of SM may help researchers and clinicians to improve early identification and treatment of SM in culturally and linguistically diverse children.

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.

A systematic review and meta-analysis of nonpharmacological interventions for children and adolescents with selective mutism

Background

Selective mutism (SM) is an anxiety disorder that often starts in early years with serious and lasting consequences. Nonpharmacological interventions are commonly seen as the preferred first treatment. This systematic review identifies outcome measures used and outcomes achieved for nonpharmacological interventions for children and adolescents with SM.

Methods

Systematic searches were conducted using 13 electronic databases and hand searches, including peer-reviewed and grey literature since 1992.

Results

Twenty-five studies were identified. While specific measures varied, all studies reported an outcome measure for speaking behaviour and 18 used a measure of anxiety. Few studies reported measures of SM remission (k = 6), well-being (k = 6), academic impact (k = 2), or quality of life (k = 1). Within subject outcomes for nonpharmacological interventions were variable for improvements in speaking behaviours (very small to large positive effects) and reduction in anxiety symptoms (very small negative to large positive effects). Only five randomised controlled trials (RCTs) were included in the meta-analysis. Three studies compared a combined systems/behavioural approach with waitlist controls indicating a significant and large effect (Hedges g = 1.06, p < .0001, 95% CI: 0.57-1.56) on improved speaking behaviour. Two of these RCTs showed a large effect for SM remission favouring the intervention (Risk Ratio = 4.25, p = .1774, 95% CI: 0.52-34.84) but this did not reach statistical significance. Non-significant outcomes for two RCTs with active controls (Hedges g = 0.55, p < .2885, 95% CI: -0.47 to 1.57) showed considerable heterogeneity in approach and outcomes, one with large and one with negligible effects.

Conclusion

Despite the considerable impairment caused by SM, there has been little systematic evaluation of non-pharmacological interventions. Although combined systems/behavioural interventions are promising, further systematic evaluations are urgently needed to inform treatment approaches. Cross-study measurement harmonisation is required to promote learning from all studies, including wider clinical and economic outcomes.

Clinical Trial Registration

Not applicable.

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.

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.

Beyond the language barrier: A systematic review of selective mutism in culturally and linguistically diverse children

Selective mutism is a childhood psychiatric disorder that has been associated with adverse psychological, social and educational outcomes. Although evidence suggests that culturally and linguistically diverse children might be overrepresented among children with selective mutism, a direct examination of how migration or minority status are associated with the development and persistence of the disorder is still scarce. Guided by eco-cultural perspectives of development, the current review aims to provide an overview of selective mutism in culturally and linguistically diverse children. A systematic literature review of selective mutism studies that included a group of culturally and linguistically diverse children yielded eight studies that met our inclusion criteria. Although these studies support the view that bilingualism and minority status might be associated with selective mutism, the role of sociocultural factors in the development and persistence of the disorder remained mostly unexamined. The review concludes with a discussion of potential directions for future research, including examination of the cultural and psychological meanings of silence and talk, socialization goals, gender inequality, and parental acculturation strategies.

Feasibility and Acceptability of a Compressed Caregiver Training Program to Treat Child Behavior Problems

In an effort to address some of the criticisms of Behavioral Parent Training programs (BPT; high attrition, reliance on caregiver report measures), the current study examined the feasibility, acceptability, and outcome of an intensive behavior treatment program (120-minute sessions for 5 days/week over the course of 2 weeks). Using a changing criterion single case experimental design, 12 children ( M child age = 4.9 years) and their primary caregivers completed the 2-week function-based intervention procedure designed to increase children’s frustration tolerance via a wait training procedure based on the principles of applied behavior analysis. Using both direct observation and standardized measures, results indicated that the treatment was effective in reducing childhood behavior problems, both within and between appointments (Cohen’s ds = 3.2 and 1.37, respectively). Preliminary evidence suggests that a compressed treatment package designed to train caregivers in function-based intervention strategies is feasible and acceptable.

Screening for Anxiety in Children and Adolescents: Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Anxiety in children and adolescents is associated with impaired functioning, educational underachievement, and future mental health conditions.

Objective

To review the evidence on screening for anxiety in children and adolescents to inform the US Preventive Services Task Force.

Data Sources

PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022.

Study Selection

English-language, randomized clinical trials (RCTs) of screening; diagnostic test accuracy studies; RCTs of cognitive behavioral therapy (CBT) or US Food and Drug Administration-approved pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms.

Data Extraction and Synthesis

Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.

Main Outcomes and Measures

Test accuracy, symptoms, response, remission, loss of diagnosis, all-cause mortality, functioning, suicide-related symptoms or events, adverse events.

Results

Thirty-nine studies (N = 6065) were included. No study reported on the direct benefits or harms of screening on health outcomes. Ten studies (n = 3260) reported the sensitivity of screening instruments, ranging from 0.34 to 1.00, with specificity ranging from 0.47 to 0.99. Twenty-nine RCTs (n = 2805) reported on treatment: 22 on CBT, 6 on pharmacotherapy, and 1 on CBT, sertraline, and CBT plus sertraline. CBT was associated with gains on several pooled measures of symptom improvement (magnitude of change varied by outcome measure), response (pooled relative risk [RR], 1.89 [95% CI, 1.17 to 3.05]; n = 606; 6 studies), remission (RR, 2.68 [95% CI, 1.48 to 4.88]; n = 321; 4 studies), and loss of diagnosis (RR range, 3.02-3.09) when compared with usual care or wait-list controls. The evidence on functioning for CBT was mixed. Pharmacotherapy, when compared with placebo, was associated with gains on 2 pooled measures of symptom improvement-mean difference (Pediatric Anxiety Rating Scale mean difference, -4.0 [95% CI, -5.5 to -2.5]; n = 726; 5 studies; and Clinical Global Impression-Severity scale mean difference, -0.84 [95% CI, -1.13 to -0.55]; n = 550; 4 studies) and response (RR, 2.11 [95% CI, 1.58 to 2.98]; n = 370; 5 studies)-but was mixed on measures of functioning. Eleven RCTs (n = 1293) reported harms of anxiety treatments. Suicide-related harms were rare, and the differences were not statistically significantly different.

Conclusions and Relevance

Indirect evidence suggested that some screening instruments were reasonably accurate. CBT and pharmacotherapy were associated with benefits; no statistically significant association with harms was reported.

Remote Intensive Group Behavioral Treatment for Families of Children with Selective Mutism

Selective mutism (SM) is a relatively rare, but highly interfering, child anxiety disorder characterized by a consistent failure to speak in certain situations, despite demonstrating fluent speech in other contexts. Exposure-based cognitive behavioral therapy and Parent-Child Interaction Therapy adapted for SM can be effective, but the broad availability and accessibility of such specialty care options remains limited. Stay-at-home guidelines to mitigate the spread of COVID-19 further limited the accessibility of office-based specialty care for SM. Building on separate lines of research supporting intensive treatments and telehealth service delivery models, this paper is the first to describe the development, preliminary feasibility, acceptability, and efficacy of a Remote Intensive Group Behavioral Treatment (IGBT) for families of young children with SM (N=9). Treatment leveraged videoconferencing technology to deliver caregiver training sessions, lead-in sessions, 5 consecutive daily IGBT sessions, and an individualized caregiver coaching session. Remote IGBT was found to be both feasible and acceptable. All families (100%) completed diagnostic assessments and caregiver-report questionnaires at four major study timepoints (i.e., intake, pre-treatment, post-treatment, 4-month follow-up) and participated in all treatment components. Caregivers reported high treatment satisfaction at post-treatment and 4-month follow-up and low levels of burden associated with treatment participation at post-treatment. Approximately half of participating children were classified as treatment responders by independent evaluators at post-treatment and 4-month follow-up. Although these pilot results should be interpreted with caution, the present work underscores the potential utility of using videoconferencing to remotely deliver IGBT to families in their natural environments.

Characteristics of person, place, and activity that trigger failure to speak in children with selective mutism

Selective Mutism (SM) is an anxiety disorder with predictable and circumscribed situations in which children remain silent while they speak unaffectedly in others. However, core features of anxiety inducing stimuli have rarely been studied so far. Parents of children with elevated SM symptomatology participated in an online-based study and answered open ended questions about specific characteristics of a person, place, and activity that elicit failure to speak in their child. The final sample consisted of n = 91 parents with children aged between 3 and 17 years (M = 8.02 years, SD = 3.94). Answers were analyzed by qualitative content analysis. Characteristics of a person were assigned to five categories with lack of distance as the most frequently reported feature. With respect to a place, the majority of parents mentioned unknown places as a silence trigger. The most frequently mentioned feature of an activity that was designated to be associated to silence was new activity. There were only few associations between the designation of these features, age, and gender. For the first time, anxiety inducing triggers related to person, place, and activity were comprehensively assessed in children with SM. This allows a differentiated and deeper understanding of an understudied disorder. The majority of characteristics can be associated with proposed etiological factors such as increased behavioral inhibition, conditioning processes, social anxiety, and a strong need for control. Implications for effective treatments are discussed.

Efficacy of psychological interventions for selective mutism in children: A meta-analysis of randomized controlled trials

BACKGROUND

Selective mutism is a rare childhood anxiety disorder characterized by a consistent failure to speak in certain social situations where speech is expected, despite fluent speech in other situations. The purpose of this meta-analysis was to investigate the efficacy of psychological interventions for selective mutism in randomized controlled trials (RCTs).

METHODS

Five RCTs with a total of 233 participants were analysed using a random-effects model. A quality assessment of the included studies revealed that psychometrically sound measures and treatment manuals were used across all studies.

RESULTS

The results of the analyses showed psychological interventions to be more effective than no treatment, with the overall weighted effect size of g = 0.87, indicating a large mean treatment effect. This effect did not significantly differ with whether only selective mutism specific or nonselective mutism specific measures were included in the analysis.

CONCLUSIONS

These findings provide support for the efficacy of psychological treatment for selective mutism. Future research could examine the effects of the successful treatments identified in this meta-analysis when compared with a psychological placebo or another bona fide treatment.

Therapist-Led, Internet-Delivered Treatment for Early Child Social Anxiety: A Waitlist-Controlled Evaluation of the iCALM Telehealth Program

Despite recent advances in the treatment of early child social anxiety, the broad accessibility of brick-and-mortar services has been limited by traditional barriers to care, and more recently by new obstacles related to efforts to slow the spread of COVID-19. The present waitlist-controlled trial examined the preliminary efficacy of a family-based behavioral parenting intervention (i.e., the iCALM Telehealth Program) that draws on Parent-Child Interaction Therapy and videoconferencing to remotely deliver clinician-led care for anxiety in early childhood. Young children (3-8 years) with a diagnosis of social anxiety disorder (N = 40; 65% from ethnic/racial minority backgrounds) were randomly assigned to iCALM or waitlist. Intent-to-treat analyses found that at post, independent evaluators classified roughly half of the iCALM-treated children, but only 6% of waitlist children, as "Responders" (Wald test = 4.51; p = .03). By Post, iCALM led to significantly greater reductions than waitlist in child anxiety symptoms, fear, discomfort, and anxiety-related social impairment, and also led to greater improvements in child soothability. By 6-month follow-up, the percentage of iCALM-treated children classified as "Responders" rose to roughly 60%. Exploratory moderation tests found iCALM was particularly effective in reducing life impairments and parental distress among families presenting with higher, relative to lower, levels of baseline parental accommodation. The present findings add to a growing body of research supporting the promise of technology-based strategies for broadening the portfolio of options for delivering clinician-led mental health services.

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.

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

In current classification systems, selective mutism (SM) is included in the broad anxiety disorders category. Indeed, there is abundant evidence showing that anxiety, and social anxiety in particular, is a prominent feature of SM. In this article, we point out that autism spectrum problems in addition to anxiety problems are sometimes also implicated in SM. To build our case, we summarize evidence showing that SM, social anxiety disorder (SAD), and autism spectrum disorder (ASD) are allied clinical conditions and share communalities in the realm of social difficulties. Following this, we address the role of a prototypical class of ASD symptoms, restricted and repetitive behaviors and interests (RRBIs), which are hypothesized to play a special role in the preservation and exacerbation of social difficulties. We then substantiate our point that SM is sometimes more than an anxiety disorder by addressing its special link with ASD in more detail. Finally, we close by noting that the possible involvement of ASD in SM has a number of consequences for clinical practice with regard to its classification, assessment, and treatment of children with SM and highlight a number of directions for future research.

Measuring Irritability in Early Childhood: A Psychometric Evaluation of the Affective Reactivity Index in a Clinical Sample of 3- to 8-Year-Old Children

The parent-report Affective Reactivity Index (ARI-P) is the most studied brief scale specifically developed to assess irritability, but relatively little is known about its performance in early childhood (i.e., ≤8 years). Support in such populations is particularly important given developmental shifts in what constitutes normative irritability across childhood. We examined the performance of the ARI-P in a diverse, treatment-seeking sample of children ages 3 to 8 years (N = 115; mean age = 5.56 years; 58.4% from ethnic/racial minority backgrounds). In this sample, confirmatory factor analysis supported the single-factor structure of the ARI-P previously identified with older youth. ARI-P scores showed large associations with another irritability index, as well as small-to-large associations with aggression, anxiety, depression, and attention problems, supporting the convergent and concurrent validity of the ARI-P when used with children in this younger age range. Findings support the ARI-P as a promising parent-report tool for assessing irritability in early childhood, particularly in clinical samples.

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.

Psychometric propierties of the Selective Mutism Questionnaire in Spanish children

Research on selective mutism (SM) has been limited by the absence of standardised, psychometrically sound and cross-culturally valid assessment measures. Our aim is to present the results of a study of the factor structure and the reliability and concurrent validity of the scores of the Selective Mutism Questionnaire (SMQ), translated and adapted into Spanish. The SMQ contains 17 items about children's difficulty in speaking adequately in the family, school and social environment (out-of-school and out-of-family), each of which is answered according to a Likert scale with four response alternatives on speech frequency. Method: The study involved 110 pairs of parents of children diagnosed with SM whose ages ranged from 3 to 10 years. Results: The results show that the data from the Spanish sample fit the factorial model obtained by Bergman et al., and that data on its reliability and validity are robust and confirm that it as a good instrument for assessing SM in Spanish-speaking children. Conclusions: Therefore, we can affirm that the SMQ is a good instrument to assess SM in Spanish-speaking children.

Using Evaluative Criteria to Review Youth Anxiety Measures, Part II: Parent-Report

This Evidence Base Update of parent-report measures of youth anxiety symptoms is a companion piece to our update on youth self-report anxiety symptom measures (Etkin et al., 2021). We rate the psychometric properties of the parent-report measures as Adequate, Good, or Excellent using criteria developed by Hunsley and Mash (2008) and Youngstrom et al. (2017). Our review reveals that the evidence base for parent-report measures is considerably less developed compared with the evidence base for youth self-report measures. Nevertheless, several measures, the parent-report Screen for Child Anxiety-Related Emotional Disorders, Multidimensional Anxiety Scale for Children, and Spence Children's Anxiety Scale, were found to have Good to Excellent psychometric properties. We conclude our review with suggestions about which parent-report youth anxiety measures are best suited to perform different assessment functions and directions for additional research to expand and strengthen the evidence base.

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.

Cognitive behavioural therapy for anxiety disorders in children and adolescents

BACKGROUND

Previous Cochrane Reviews have shown that cognitive behavioural therapy (CBT) is effective in treating childhood anxiety disorders. However, questions remain regarding the following: up-to-date evidence of the relative efficacy and acceptability of CBT compared to waiting lists/no treatment, treatment as usual, attention controls, and alternative treatments; benefits across a range of outcomes; longer-term effects; outcomes for different delivery formats; and amongst children with autism spectrum disorders (ASD) and children with intellectual impairments.

OBJECTIVES

To examine the effect of CBT for childhood anxiety disorders, in comparison with waitlist/no treatment, treatment as usual (TAU), attention control, alternative treatment, and medication.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (all years to 2016), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO (each to October 2019), international trial registries, and conducted grey literature searches.

SELECTION CRITERIA

We included randomised controlled trials of CBT that involved direct contact with the child, parent, or both, and included non-CBT comparators (waitlist/no treatment, treatment as usual, attention control, alternative treatment, medication). Participants were younger than age 19, and met diagnostic criteria for an anxiety disorder diagnosis. Primary outcomes were remission of primary anxiety diagnosis post-treatment, and acceptability (number of participants lost to post-treatment assessment), and secondary outcomes included remission of all anxiety diagnoses, reduction in anxiety symptoms, reduction in depressive symptoms, improvement in global functioning, adverse effects, and longer-term effects.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 87 studies and 5964 participants in quantitative analyses. Compared with waitlist/no treatment, CBT probably increases post-treatment remission of primary anxiety diagnoses (CBT: 49.4%, waitlist/no treatment: 17.8%; OR 5.45, 95% confidence interval (CI) 3.90 to 7.60; n = 2697, 39 studies, moderate quality); NNTB 3 (95% CI 2.25 to 3.57) and all anxiety diagnoses (OR 4.43, 95% CI 2.89 to 6.78; n = 2075, 28 studies, moderate quality). Low-quality evidence did not show a difference between CBT and TAU in post-treatment primary anxiety disorder remission (OR 3.19, 95% CI 0.90 to 11.29; n = 487, 8 studies), but did suggest CBT may increase remission from all anxiety disorders compared to TAU (OR 2.74, 95% CI 1.16 to 6.46; n = 203, 5 studies). Compared with attention control, CBT may increase post-treatment remission of primary anxiety disorders (OR 2.28, 95% CI 1.33 to 3.89; n = 822, 10 studies, low quality) and all anxiety disorders (OR 2.75, 95% CI 1.22 to 6.17; n = 378, 5 studies, low quality). There was insufficient available data to compare CBT to alternative treatments on post-treatment remission of primary anxiety disorders, and low-quality evidence showed there may be little to no difference between these groups on post-treatment remission of all anxiety disorders (OR 0.89, 95% CI 0.35 to 2.23; n = 401, 4 studies) Low-quality evidence did not show a difference for acceptability between CBT and waitlist/no treatment (OR 1.09, 95% CI 0.85 to 1.41; n=3158, 45 studies), treatment as usual (OR 1.37, 95% CI 0.73 to 2.56; n = 441, 8 studies), attention control (OR 1.00, 95% CI 0.68 to 1.49; n = 797, 12 studies) and alternative treatment (OR 1.58, 95% CI 0.61 to 4.13; n=515, 7 studies). No adverse effects were reported across all studies; however, in the small number of studies where any reference was made to adverse effects, it was not clear that these were systematically monitored. Results from the anxiety symptom outcomes, broader outcomes, longer-term outcomes and subgroup analyses are provided in the text. We did not find evidence of consistent differences in outcomes according to delivery formats (e.g. individual versus group; amount of therapist contact time) or amongst samples with and without ASD, and no studies included samples of children with intellectual impairments.

AUTHORS' CONCLUSIONS

CBT is probably more effective in the short-term than waiting lists/no treatment, and may be more effective than attention control. We found little to no evidence across outcomes that CBT is superior to usual care or alternative treatments, but our confidence in these findings are limited due to concerns about the amount and quality of available evidence, and we still know little about how best to efficiently improve outcomes.

The Selective Mutism Questionnaire: Data from typically developing children and children with selective mutism

The core symptom of the anxiety disorder selective mutism (SM) is absence of speech in specific situations, such as at school. The most commonly used standardized instruments to assess speaking behavior are the parent-rated Selective Mutism Questionnaire (SMQ) and the teacher-rated School Speech Questionnaire (SSQ), scored from 0 to 3, indicating that speaking behavior never, seldom, often, and always occur. They were developed to assess severity of mutism and potential effects of treatment. However, prospective data on speaking behavior in typically developing children (TDs) are missing in the literature. The main aim of this study was to present data from TDs over time with previously reported data from children treated for SM, as a comparison. Participants were 64 children aged 3-9 years, 32 TDs who were a matched control group to 32 children with SM. At baseline, the mean SMQ and SSQ scores were ⩾2.5 in TDs and 0.5 in children with SM. The TDs did not show significant changes over time, while significantly increased speech was found in children with SM after treatment. Thus, our findings support the use of the SMQ/SSQ to assess baseline SM severity and to evaluate potential treatment effects in future studies.

Effectiveness of a behavioral treatment protocol for selective mutism in children: Design of a randomized controlled trial

Selective mutism (SM) is a relatively rare anxiety disorder, characterized by a child's consistent failure to speak in various specific social situations (e.g., at school), while being able to speak in other situations (e.g., at home). Prevalence rates vary from 0.2% to 1.9%. SM is usually identified between the ages of 3-5 years. It is often underdiagnosed and consequently children receive no or inadequate treatment, with negative consequences for school and social functioning. If left untreated, SM can result in complex, chronic anxiety and/or mood disorders in adolescence and impaired working careers in adulthood. Currently, no evidence-based treatment for SM is available in the Netherlands, therefore this study aims to [1] test the effectiveness of a treatment protocol for SM that is carried out at school, and to [2] identify baseline predictors for treatment success. This article presents the design of a randomized controlled trial into the effectiveness of a behavioral therapeutic protocol for selective mutism in children (age 3-18). The expected study population is n = 76. Results of the treatment group (n = 38) will be compared with those of a waiting list control group (WCG) (n = 38). Pre and post treatment assessments will be conducted at comparable moments in both groups, with baseline assessment at intake, the second assessment at 12 weeks and post-assessment at the end of treatment. If proven effective, we aim to structurally implement this protocol as evidence-based treatment for SM.

Behavioral Assessment and Treatment of Selective Mutism in Identical Twins

Selective mutism (SM) is a childhood disorder characterized by persistent failure to speak in situations where speech is expected. There is evidence that behavioral interventions are effective for increasing speech in children with SM but studies have been limited by small, relatively homogeneous samples. Although twins appear to be disproportionately represented among children with SM, little is known about their specific treatment needs and barriers to effective treatment implementation in this population. This case study presents family-based behavioral therapy delivered to a set of 8-year-old, identical twins with SM. At posttreatment, both children displayed marked improvements in speaking and social engagement. Clinical considerations for working with twins with SM are discussed.

Condensing parent training: A randomized trial comparing the efficacy of a briefer, more intensive version of Parent-Child Interaction Therapy (I-PCIT)

OBJECTIVE

The current study examined the comparative efficacy of a more intensive version of Parent-Child Interaction Therapy (I-PCIT; 5 days/week over 2 weeks) versus a time-limited weekly PCIT format (1 day/week over 10 weeks) in treating early childhood externalizing behavior problems.

METHOD

Using a randomized trial design, 60 young children (mean age [Mage] = 4.33 years; 65% male; 85% Latinx) with clinically elevated levels of externalizing behavior problems and their parents were assigned to either I-PCIT (n = 30) or time-limited PCIT (n = 30). Families completed pre-, post-, and follow-up assessments 6-9 months following treatment completion. Parents completed measures of child behavior, discipline practices, and parenting stress. Observational data on child behavior and parenting were also collected.

RESULTS

Noninferiority and multivariate repeated-measures analyses indicated comparable improvements across 6 out of 7 observed and parent-reported outcomes, including parenting skills, discipline practices, and child externalizing behavior problems at posttreatment. Comparable treatment gains remained at follow-up, with the caveat that parents in time-limited PCIT reported lower externalizing behavior problems compared with I-PCIT, although both groups were still significantly better compared with pretreatment. Lastly, moderation analyses indicated that parents experiencing high levels of stress benefited more from I-PCIT in terms of decreasing child externalizing behavior compared with time-limited PCIT.

CONCLUSIONS

I-PCIT appears to be a viable treatment option for families, especially those experiencing high levels of stress, in terms of targeting early externalizing behavior problems within a short period of time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Examining a novel, parent child interaction therapy-informed, behavioral treatment of selective mutism

BACKGROUND

The purpose of this study was to evaluate a new therapy for children with selective mutism (SM) that combines Parent-Child Interaction Therapy principles and behavioral techniques.

METHOD

Children aged 4-10 with a primary diagnosis of SM were eligible to participate. Comorbidity was allowed with the exception of autism spectrum disorder, intellectual disability, mania or psychosis. Of 54 potentially eligible participants, 33 met inclusion/exclusion criteria of which 31 families consented (94%). Following assessment, children were waitlisted for an average of 4 months before receiving 16 sessions of weekly therapy at an outpatient psychiatry clinic of a children's hospital in Vancouver, Canada; all children completed treatment. Assessments were conducted at time of referral (baseline), pre-treatment, post-treatment, 3 month follow up, and 1 year follow up. Two did not complete follow up assessments (93% retention).

RESULTS

Results showed significant and large (Cohen's d = 1.80) gains in speaking behaviors across contexts from pre- to post-treatment. Gains were maintained at 3-months and 1-year post-treatment. Statistically significant and large improvements were also found in post-treatment teacher and parent reports of child anxiety as well as a behavioral measure of the child speaking to an unknown adult. Parents reported high satisfaction with treatment. None of the potential predictors of treatment response examined were found to be significant.

CONCLUSIONS

PCIT-SM appears to be an effective treatment for children aged 4-10 with SM.