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anxiety:selective-mutism [on April 12, 2019]
anxiety:selective-mutism [on March 29, 2021] (current)
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 ===== Primer ===== ===== Primer =====
-**Selective Mutism** is a condition ​where individuals (most commonly children) do not initiate speech or reciprocally respond when spoken to by others. This lack of speech occurs in both social interactions with children or adults. Children ​with selective mutism ​will speak in their home in the presence of immediate family members ​but often not even in front of close friends or second-degree relatives, such as grandparents or cousins. The mutism often carries with it high social anxiety+**Selective Mutism** is a mental disorder ​where individuals (most commonly children) do not initiate speech or reciprocally respond when spoken to by others. This lack of speech occurs in both social interactions with children or adults. Children will however, ​speak in their home in the presence of immediate family members.
  
-Children with selective ​mutism ​often refuse to speak at school, ​leading ​to academic ​or educational impairmentas teachers ​often find it difficult ​to assess skills such as reading. The lack of speech ​may interfere with social communicationalthough children with this disorder ​sometimes use nonspoken or nonverbal means (e.g., gruntingpointing, writingto communicate ​and may be willing or eager to perform or engage in social encounters when speech is not required ​(e.g., nonverbal parts in school plays).+== Epidemiology == 
 +  * Selective ​mutism ​is rare, and the point prevalence using various clinic or school ​samples ranges between 0.03% and 1%.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). ArlingtonVA.)] 
 +  * There does not appear ​to be a sex or ethnicity difference. 
 +  * It is more likely to occur in young children than adults.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). ArlingtonVA.)] 
 + 
 +== Prognosis == 
 +  * The onset of selective mutism usually begins before age 5 years 
 +  * It often comes to clinical attention when the school age years begin and there is a need for social interactions and performance tasks. 
 +    * This can lead to severe impairment in social or school functioning,​ or teasing from peers. 
 +  * The course ​of selective mutism is unclear, but most individuals will outgrow the symptoms. 
 +    * Social anxiety symptoms ​may continue howeverand individuals may continue to meet criteria for this disorder.[(American Psychiatric Association(2013)Diagnostic and Statistical Manual of Mental Disorders (5th ed.). ArlingtonVA.)] 
 + 
 +== Comorbidity == 
 +  * In the clinical settingchildren with selective mutism are almost always given an additional diagnosis of social anxiety disorder.[(American Psychiatric Association. (2013). Diagnostic ​and Statistical Manual of Mental Disorders ​(5th ed.)ArlingtonVA.)]
  
 == Risk Factors == == Risk Factors ==
-Selective ​mutism ​is more common in females than males+  * Children may model parents who have social inhibition, which increases risk for selective ​mutism.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
-===== Diagnostic Criteria ===== +  * Parents who are described as overprotective may have children at increased risk for selective mutism. 
-<WRAP group> + 
-<WRAP half column>+===== DSM-5 Diagnostic Criteria =====
 == Criterion A == == Criterion A ==
-Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g.at school) despite speaking in other situations.+Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g. at school) despite speaking in other situations. 
 == Criterion B == == Criterion B ==
 The disturbance interferes with educational or occupational achievement or with social communication. The disturbance interferes with educational or occupational achievement or with social communication.
 +
 == Criterion C == == Criterion C ==
-The duration of the disturbance is at least ''​1''​ month (not limited to the first month of school). +The duration of the disturbance is at least ''​1''​ month (cannot be during ​first month of school). 
-</​WRAP>​ +
-<WRAP half column>+
 == Criterion D == == Criterion D ==
 The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
 +
 == Criterion E == == Criterion E ==
-The disturbance is not better explained by a communication disorder (e.g.childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia,​ or another psychotic disorder.+The disturbance is not better explained by a communication disorder (e.g. - [[child:​communication:​childhood-onset-fluency-disorder|childhood-onset fluency disorder]]) and does not occur exclusively during the course of [[child:​asd|autism spectrum disorder]][[psychosis:​schizophrenia-scz|schizophrenia]], or another ​[[psychosis:​home|psychotic disorder]].
  
-</WRAP+==== Specifiers ==== 
-</WRAP>+{{page>anxiety:​gad#​specifiers&​nouser&​noheader&​nodate&​nofooter}} 
 + 
 +==== Signs and Symptoms ==== 
 +  * Children with selective mutism often refuse to speak at school, which can cause academic or educational impairment. 
 +  * The lack of speech can also interfere with social communication. Children may sometimes use nonspoken or nonverbal methods (e.g. - grunting, pointing, writing) to communicate. 
 +  * They may similarly be willing or eager to perform or engage in social encounters when speech is not required (e.g. - nonverbal parts in school plays). 
 +  * Generally, children with selective mutism have normal language skills. 
 + 
 +===== Screening and Rating Scales ===== 
 +  * Selective Mutism Questionnaire (SMQ)[([[https:​//​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2925837/​|Letamendi,​ A. M., Chavira, D. A., Hitchcock, C. A., Roesch, S. C., Shipon-Blum,​ E., & Stein, M. B. (2008). Selective mutism questionnaire:​ Measurement structure and validity. Journal of the American Academy of Child & Adolescent Psychiatry, 47(10), 1197-1204.]])] 
 + 
 +===== Pathophysiology ===== 
 +  * The underlying psychopathology and pathophysiology of selective mutism is thought to be similar to [[anxiety:​social-anxiety|social anxiety disorder]] due to their many overlapping features. 
 + 
 +===== Differential Diagnosis ===== 
 +  * **[[child:​communication:​home|Communication disorders]]** 
 +    * Selective mutism should be differentiated from speech disturbances due to a communication disorder, such as [[child:​communication:​language-disorder|language disorder]], [[child:​communication:​speech-sound-disorder|speech sound disorder]], [[child:​communication:​childhood-onset-fluency-disorder|childhood-onset fluency disorder]] (stuttering),​ or [[child:​communication:​social-pragmatic-communication-disorder|pragmatic (social) communication disorder]]. 
 +    * Unlike selective mutism, the speech disturbance in these other conditions is not restricted to a specific social situation. 
 +  * **Neurodevelopmental disorders and schizophrenia and other psychotic disorders** 
 +    * Individuals with an [[child:​asd|autism spectrum disorder]], [[psychosis:​schizophrenia-scz|schizophrenia]] or another [[psychosis:​home|psychotic disorder]], or severe [[child:​intellectual-disability|intellectual disability]] may have problems in social communication and be unable to speak appropriately in social situations. 
 +    * In contrast, selective mutism should be diagnosed only when a child has an established capacity to speak in some social situations (e.g. - typically at home). 
 +  * **[[anxiety:​social-anxiety|Social anxiety disorder (social phobia)]]** 
 +    * Social anxiety disorder and selective mutism have a high overlap in the symptom criteria. Commonly, an individual with selective mutism will also receive a diagnosis of social anxiety disorder.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
  
 +===== Investigations =====
 +  * As clinically indicated.
 +===== Physical Exam =====
 +  * As clinically indicated.
  
 +===== Treatment =====
 +==== Psychotherapy ====
 +  * [[psychotherapy:​cbt|Cognitive behavioural therapy]] is the main treatment for selective mutism. Exposure is the most important component, and involves gradually exposing the child to speaking tasks with parental/​therapist support.[([[https://​pubmed.ncbi.nlm.nih.gov/​29357099/​|Oerbeck,​ B., Overgaard, K. R., Stein, M. B., Pripp, A. H., & Kristensen, H. (2018). Treatment of selective mutism: A 5-year follow-up study. European child & adolescent psychiatry, 27(8), 997-1009.]])]
 +===== Guidelines =====
 +  * [[https://​pubmed.ncbi.nlm.nih.gov/​7649953/​|Dow,​ S. P. et al. (1995). Practical guidelines for the assessment and treatment of selective mutism. Journal of the American Academy of Child & Adolescent Psychiatry, 34(7), 836-846.]]
 ===== Resources ===== ===== Resources =====
  
 <WRAP group> <WRAP group>
 <WRAP quarter column> <WRAP quarter column>
-==== For Patients ====+== For Patients == 
 +  * [[https://​www.selectivemutism.org/​|Selective Mutism Association]]
  
 </​WRAP>​ </​WRAP>​
  
 <WRAP quarter column> <WRAP quarter column>
-==== For Providers ​====+== For Providers ==
  
 </​WRAP>​ </​WRAP>​