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.

Feasibility trial of virtual reality exposure therapy for selective mutism

Virtual reality exposure therapy (VRET) has been commonly utilised as an extension of cognitive behavioural therapy (CBT). However, most studies examined its effectiveness among adults, with no study focusing on children with selective mutism (SM). We aimed to examine its feasibility and acceptability among children with SM. Twenty children aged 6–12 with SM diagnosis were recruited and completed six therapist-guided VRET sessions. Parents and clinicians completed measures at pre-VRET, post-VRET, 1-month and 3-month follow-up visits. At post-VRET, parent and child participants completed the acceptability questionnaires. Findings suggested the feasibility of VRET as all participants completed the programme with no attrition. Parents and child participants also reported VRET to be an acceptable and effective treatment for SM. Significant improvement in overall functioning were found at post-treatment and follow-up measures, but there were no significant changes in parent-rated speech frequency and anxiety measures. These support the acceptability of VRET as an adjunct modality (and not substitute) of CBT in SM treatment. Future studies, with more robust experimental designs and larger sample sizes, can be conducted to confirm its efficacy. As technology becomes more sophisticated, tools such as virtual environments can be explored to enhance evidence-based care for children and their families.

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.

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.

Definitions, importance, and application of selective mutism questionnaire in the primary care setting

Children with selective mutism might suffer from less frequent involvement in school activities, reduced social and cognitive abilities, in addition to being at increased risk of subjective suffering and developing other associated morbidities. There is a lack of evidence regarding the assessment modalities that should be used to evaluate selective mutism. However, recent data show that the selective mutism questionnaire (SMQ) is validated among different investigations with well-established psychometric properties. In the present literature review, we have discussed the definition, uses, and importance of the SMQ for children with selective mutism in primary care settings. Our results show that the different included studies indicate the sensitivity and reliability of the tool to assess the severity of behavioral speaking among these children. Besides, evidence has shown that the tool can be used to assess the impact of treatment on the behavioral outcomes of these children. Based on these data, it has been demonstrated that the treatment of selective mutism can significantly enhance the scores and the behavioral speaking patterns. However, these scores were still relatively lower than the ones estimated for the typically developing children. The impact of more intensive treatment modalities has been suggested but was not adequately validated, and therefore, further research is a must for adequate interpretation and validation of the current findings to achieve better outcomes.

A Review on Pediatric Social Phobia and Selective Mutism

Selective mutism (SM) is a psychological disease that affects children and is defined by a complete lack of speech in certain social contexts while speech production appears normal in others. Separation anxiety disorder, social anxiety disorder (previously known as social phobia), agoraphobia, and panic disorder, as well as shyness and anxiety, can all be associated with selective mutism. SM is a rather uncommon condition. Estimates of its point prevalence have been found in clinic or school samples in a variety of countries, and typically range between 0.03 percent and 1.9 percent depending on the setting. To properly establish the disorder's diagnosis, clinicians can use the SM module of the Anxiety Disorders Interview Schedule for Children and Parents (ADIS-C/P) or the Schedule for Affective Disorders and Schizophrenia for Children (Kiddie- or K-SADS). Nonmedication and medication-based therapies are the two basic types of treatment for selective mutism. Psychodynamic therapy, behavioural therapy, and family therapy are among the most common nonmedication-based or psychotherapy treatments. Selective seratonin reuptake inhibitors (SSRIs) (fluoxetine in particular) have been demonstrated to improve mutism and anxiety when used as a treatment option. The study aims to evaluate and treat selective silence and social phobia in children.

Improving Communication Ability of a Child with Selective Mutism Through “Kita Semua Sahabat” Training

Selective Mutism (SM) is characterized by failure to speak at some period of time in specific social situations (e.g., at school), but can talk in other familiar situations (home). This study aimed to determine the effectiveness of ‘Kita Semua Sahabat’ in improving communication skills in children with SM. The subject was a 5 year-old boy who had been diagnosed based on DSM-V. The research design was a single case experimental design. Interventions were performed using the technique of stimulus fading and contingency management which were packed through the training of ‘Kita Semua Sahabat’. The result showed that there was a significant increase, and communication with stimulus (prompts) had a greater increase than communication without stimulus (child’s initiation). The research showed that Training ‘Kita Semua Sahabat’ is effective to increase communication among children with SM, and more frequent verbal communication happens if more stimuli were given to the child.

Betrayed by the nervous system: a comparison group study to investigate the ‘unsafe world’ model of selective mutism

The study presented in the following verifies some assumptions of the novel ‘unsafe world’ model of selective mutism (SM). According to this model, SM is a stress reaction to situations erroneously experienced via cognition without awareness as ‘unsafe’. It assumes a high sensitivity to unsafety, whereby the nervous system triggers dissociation or freeze mode at relatively low thresholds. We examine whether there is a correlation between SM, sensory-processing sensitivity and dissociation. We compared a sample of 28 children and adolescents with SM (mean age 12.66 years; 18 females) to 33 controls without SM (mean age 12.45 years; 21 females). Both groups were compared using a medical history sheet, the ‘Selective Mutism Questionnaire’ (SMQ), a ‘Checklist for Speaking Behaviour’ (CheckS), the ‘Highly Sensitive Person Scale’ (HSPS), the ‘Child Dissociative Checklist’ (CDC), the ‘Adolescent Dissociative Experience Scale’ (A-DES) and the ‘Social Phobia and Anxiety Inventory for Children’ (SPAIK). Appropriate parametric and non-parametric tests were conducted to examine differences between groups. The results indicate that sensory-processing sensitivity was significantly higher in the group of children and adolescents with SM [X2(1) = 7.224, p = 0.0007; d = 1.092]. Furthermore, dissociative symptoms were more common in children and adolescents with SM than in controls [F(1, 33) = 13.004, p = 0.001; d = 0.986]. The results indicate that sensory-processing sensitivity and dissociation are important factors of SM that may hold important implications for the treatment. Trial Registration This study is registered with the ClinicalTrials.gov number NCT04233905.