Prevention of complications of selective mutism (eg, school phobia, academic failure due to poor attendance) can be achieved by reinforcement by family, school, and physician of how important attending school is despite the child's desire to stay home and to avoid social events in order to reduce anxiety.
SSRIs are effective and superior to placebo, with efficacy rates of at least 65% in the treatment of patients with social phobia and the related disorder, selective mutism. The doses used in both children and adults are frequently much higher than those used for affective disorders.
Cognitive-behavioral therapy may be extremely helpful to improve the level of the child's autonomous functioning and should be performed by a clinician experienced in such therapy (eg, psychologist, psychiatrist, behavioral/developmental pediatrician). Cognitive approaches to both social phobia and selective mutism may be grouped into the several following types:
Contingency combined with stimulus fading: The desired behavior (ie, speaking out loud) is elicited with a stimulus or prompt; then, the prompt is gradually faded by decreasing the number of prompts, eventually to zero.
Behavior shaping combined with positive reinforcers: The child is rewarded every time she exhibits behavior that is closer and closer to the desired behavior (ie, speaking out loud).
Positive reinforcers: Use of positive reinforcers such as a token economy or reward system for perfect attendance at school and special treats, such as a favorite book or movie for attending social events, may be successful.
Aversive interventions: Forcing the child to speak out loud generally does not encourage the behavior to occur more often.
Systematic desensitization: The child or adolescent relearns how not to be upset or anxious when in a social situation. Instead of feeling uncomfortable in the situation, the child connects feelings of calm with the previously anxiety-provoking social situation. Instead of automatically reacting to the anxiety-provoking situation with autonomic nervous system activation, the behavioral response is reconditioned to that of relative autonomic nervous system deactivation.
Extinction: The undesired behavior (refusing to speak, hiding, refusing to go to school) is ignored, and the lack of attention to the behavior causes the behavior to cease.
Modeling: The child or adolescent learns from a peer or adult therapist how to react in a calmer manner to the stressful situation. Research studies support the efficacy of using audio tapes or videotapes in treating selective mutism.
In vitro graded exposure: The child or adolescent imagines the stressful situation starting with the least stressful aspects, learning how to deal with these, and then following up with more stress-provoking aspects. This could include the use of scripted play therapy using real-life stressful situations with targeted responses for learning and incorporation.
In vivo exposure: The situation becomes less tension-provoking with repeated graded exposures as the situation becomes less new and more predictable. Careful real-life exposure (from less-threatening to more-threatening) to anxiety-provoking situations with postexposure discussion may be helpful, as actual experience of real-life situations determines whether resolution of the abnormal emotional response has taken place.
Social problem-solving: The child or adolescent is encouraged to view the social interaction that causes anxiety as a problem to be solved; this technique can be especially helpful when combined with the use of positive reinforcers and fading of prompts.
To exclude hearing loss or other language disorder with selective mutism, obtain both a speech and language evaluation and an audiology evaluation.
If a more serious problem with interpersonal relatedness is suspected, the Childhood Autism Rating Scale (CARS) or other standardized tests may be administered by a licensed clinical psychologist to exclude childhood autism, pervasive developmental disorder, or reactive-attachment disorder. Autism and pervasive developmental disorders are behavioral diagnoses that can also be appropriately diagnosed by a pediatrician, behavioral/developmental pediatrician, pediatric neurologist, or, most appropriately, a multidisciplinary team.
Exclude suicidal behavior, self-harm, and a strong family history of suicide before treatment with paroxetine.
No specific dietary recommendations have proven efficacy in selective mutism.
Encouragement of continued normal activity is important to prevent behavioral and physical regression in skill levels in individuals with selective mutism.
SSRIs, especially fluoxetine, have demonstrated effectiveness for disabling social anxiety disorder and selective mutism. Experts postulate that SSRIs modulate anxiety symptoms both in the brain and peripherally in the gastrointestinal/autonomic nervous system. Peripheral gastrointestinal and autonomic nervous system activation account for the usual anxiety symptoms experienced (ie, cramping, dry mouth, tightness of the chest, palpitations, lightheadedness, dizziness). Drugs should be used only when symptoms significantly affect a patient's daily activities. Many people are mildly socially anxious, and only a small percentage need medication.
Before starting treatment with SSRIs and whenever increasing or decreasing medication dosage, question the patient and family whether there is a prior history of self-harm and potentially suicidal behavior. When using SSRIs, suicidal behavior and a history of self-harm can be potential contraindications to treatment with fluoxetine (or other SSRIs or SNRIs). It is also important to ask about the presence of other conditions that could potentially worsen SSRI-induced hyponatremia.
These antidepressant agents are chemically unrelated to tricyclic, tetracyclic, or other available antidepressants. They inhibit CNS neuronal uptake of serotonin (5HT) and may have a weak effect on norepinephrine and dopamine neuronal reuptake. They have been used to treat anxiety, phobias, and obsessive-compulsive disorders.
These agents potentiate serotonergic activity in the CNS that results from inhibition of neuronal reuptake of serotonin and also block the influx of serotonin into platelets. Receptor and neurohistochemical changes result in changes in modulation of emotions.
SSRIs are greatly preferred over the other classes of antidepressants because of their increased tolerability, which tends to lead to improved compliance. Recent studies by the US Food and Drug Administration (FDA) have shown an association of increased risk of suicidal ideation or attempts with SSRIs. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with a mood disorder.
Physicians are advised to be aware of the following information and to use appropriate caution when considering treatment with SSRIs in the pediatric population.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric patients treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants. This is the largest study to date to address this issue.
The FDA continues to closely monitor the risk of suicidality, particularly in children younger than 18 years who are treated with antidepressants, antiseizure medications, mood stabilizers, and stimulants. Preliminary findings have shown that longer-acting antidepressants seem less likely to cause newly onset suicidality than shorter-acting antidepressants.
DOC for social anxiety disorder because it has specific approval by the FDA for that disorder. DOC for selective mutism because this disorder is often associated with social anxiety disorder when untreated. Recommended to be administered bid to prevent withdrawal reactions. The FDA has not established the safety of this medication for children, except for those with major depressive disorders. Not recommended for use in children unless very closely supervised; FDA "Black Box" warning issued because of concerns about the risk of new-onset suicidal ideation, new-onset homicidal ideation, or self-injurious behavior. Clinical trials in the United Kingdom found a 1.5-3.2 times greater risk of self-harm and potentially suicidal behavior in children and teenagers treated with paroxetine than in those treated with placebo.
Generally, begin with 10 mg/d in divided doses bid because the half-life of the medication is 10-16 h after 1 dose and 21 h after multiple doses so that after the medication has been administered for 2-4 wk, once daily administration may give almost as good a blood level as twice daily dosage with improved patient compliance; increase dosage by not more than 10 mg/wk; morning administration recommended to minimize GI adverse effects; if giving syrup (10 mg/5 mL), instruct the parent on how to avoid overdosage. Steady-state levels take 2-6 wk to achieve.
Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. First SSRI used in children and adolescents. Relatively safe in overdose. May cause more gastrointestinal adverse effects than other SSRIs. May be given as a liquid or capsule. May give as once daily dose or in divided doses. Presence of food does not appreciably alter levels of the medication. May take up to 4-6 wk to achieve steady-state levels of the medication, as it has a long half-life. FDA approved in children 6 y and older for obsessive-compulsive disorder.
Further Inpatient Care
Further inpatient care is generally unnecessary in patients with selective mutism.
Further Outpatient Care
Formal relaxation training can be helpful, and the use of concrete depictions (that relaxation is occurring) may facilitate the process; for example, the use of a biofeedback apparatus including a computer screen that changes color or graphically depicts an increase in the height of a bar graph when a relaxation response occurs (and is measured by objective measurements such as skin conductance, pulse, or blood pressure) may be helpful.
Weekly individual cognitive-behavioral therapy and/or group therapy sessions for at least 1 hour per week with appropriate parental involvement are recommended.
Support groups for parents of children with selective mutism can be tremendously helpful.
Social skills problem-solving has shown promise.
Additional helpful items may include the following:
Supportive educational environment to guard against further additional anxiety or stressors, which worsen the patient's emotional state
Close collaboration among school, home, and community personnel (eg, athletic, music, art, religious personnel) and any therapy providers to reinforce prevention of loss of skills in other areas
Medication management (at least initially) by a child psychiatrist or pharmacologically knowledgeable behavioral-developmental pediatrician after appropriate screening, medical examination, and testing results are obtained (weekly or every other week visits until the patient is stabilized and monthly thereafter)
Group therapy (more appropriate for older children and adolescents to provide an in vivo experience but may benefit younger children if they are able to participate appropriately in a group)
Inpatient & Outpatient Medications
Adjunctive treatment with a low-dose SSRI is indicated if no improvement is observed or if the person's level of functioning deteriorates to the point of not being able to maintain at least 50% level of functioning (ie, missing 50% of days of school or work) after nonresponse to 4-6 weeks of cognitive-behavioral therapy.
It is also very helpful to determine if the individual has a comorbid language or communication disorder.
Intensive intervention with children or adolescents at high risk for anxiety disorders (eg, those who have a parent with anxiety disorder) to prevent development of phobias after traumatic experiences (eg, anesthesia) and encouragement of both the child and family to work through their emotional reactions to stressors soon after the stressor occurs may be needed.
Interestingly, children and adolescents with social phobia are less likely to develop a panic attack in response to an infusion of sodium lactate or CO2 than persons with panic disorder.
Panic disorder with and without agoraphobia
Separation anxiety disorder
Generalized anxiety disorder
The prognosis of selective mutism is fair-to-good and depends on the severity of impairment of functioning associated with avoidance of social situations and public speaking and on the presence or absence of secondary gain factors that tend to discourage persons from changing their adaptation to anxiety.
Perhaps related to the higher incidence of associated speech and language disorders, children who have social phobia when they are younger than 10 years have a better long-term prognosis. Prognosis is poorer in children older than 12 years who have social phobia than in younger children. Long-term prognosis is perhaps related to the implications of having fewer overall communication skills in social settings or with peers for long-term social skills and language skills development. Also, the baseline problems that provoke the adolescent have the potential to be more long-standing and more serious.
Mild heart rate increases and subjective sensations of a lump in the throat or abdominal discomfort are physiological reactions to stress and are to be expected. These must be differentiated from disabling panic attacks in which simple reassurance does not help. Reactions can decrease as the child or adolescent learns to relax instead of tense up when stressful situations occur.
Selective Mutism Foundation, Inc.
PO Box 13133
Sissonville, WV 25360
The website and the book (504 PLAN School Intervention and Strategies Plan for Selective Mutism) in the website above would help.