courtney keeton, phd clinical psychologist assistant professor of psychiatry the johns hopkins...
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COURTNEY KEETON, PHD
CLINICAL PSYCHOLOGISTASSISTANT PROFESSOR OF PSYCHIATRY
THE JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE
DECEMBER 3 2012
Understanding Selective Mutism
Questions Addressed
Is selective mutism (SM) the same as shyness?Does SM go away over time, or is treatment
needed?What are behavioral treatments for SM?What is the role of the school in SM treatment?When should medication be considered?How do I effectively parent my child with SM?
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What Is Selective Mutism (SM)?
The consistent failure to speak in social situations when speaking is expected Fluid speech in other situations (usually home &
familiar settings) Interferes with academic & social development Duration: at least one month (not September!) Not due to lack of knowledge/comfort with the
language Not better accounted for by communication or
developmental disorder, or psychosis
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Diagnostic Classification
DSM-IV-TR (2000) Selective Mutism
DSM-5 (May 2013) Social Anxiety Disorder (Selective Mutism)
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Clinical Presentation
Large individual variation in communication behaviors Context: school, home, public People: peers, adults, family, strangers Nonverbal Features: gestures, nods, eye
contact Verbal Features: volume, quantity,
spontaneity
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Epidemiology
1 out of 140 kids (0.7%) Comparable to other anxiety disorders such
as OCD
Gender difference: mixed data
Preschool age of onset: before age 5 Referrals typically made between 6.5 and 9
years of age
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Course
MYTH: Child will “outgrow it”
Chronic 1/3 remission 1/3 remarkably improved 1/3 minimal improvement
Risk for future impairment Social Anxiety Disorder Social skills deficits Mood problems
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Etiology
Familial/Genetic component Family history of SM, shyness, anxiety
Temperament Behavioral inhibition
Environmental vulnerability Less socially active family Autonomy-limiting parenting Negatively reinforced behavior
MYTH: trauma → SM Insidious onset
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Other Common Concerns
Other forms of anxiety Social phobia (>80%) Separation anxiety (~30%) Specific phobia (~15%) Generalized anxiety disorder (~15%) Physical symptoms
Elimination problems (~30%) Constipation Enuresis Encopresis
Oppositional behavior Communication disorders
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Assessment
Observational methods
Interviewing
Pencil-and-paper questionnaires
Speech and language assessment
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Treatment
Psychosocial Treatment
Pharmacological Treatment
Goals Reduce anxiety Increase quality and quantity of speech across people
and situations Achieve remission: spontaneous, age appropriate
conversational speech across contexts
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Psychosocial Treatment Approaches
First-line treatment = behavioral and cognitive-behavioral approaches
Cognitive Behavioral Therapy
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Basis of Psychological Problems
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Interpersonal and environmental contexts
Features of CBT
Time-limited Skill-based, problem-specific, goal-oriented
Structured (but flexible)Present and solution-focusedCollaborative Empirically-based (data shows it works!)
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CBT for SM
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CBT for SM
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Targeting Avoidant Behavior
Techniques: Graduated Exposure, Shaping, Stimulus Fading
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Show home video of self talking to doctor
Mouth the names of pictures/colors during game
Whisper counting during “Chutes & Ladders”
Ask questions during “Guess Who”
Read short story aloud
Targeting Accommodation by Others
Reduce “mind-reading” in low stress situations
Allow child a chance to respond before repeating a question
Create opportunities for speech Stay involved in social activities
(swimming, birthday parties)
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Targeting Parenting Behaviors
Create structure/routine
Encourage independence in child
Offer praise/rewards for positive behaviors
Increase child’s control during play by narrating
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Intervening at School Level
Collect teacher feedbackProvide educationSecure services through an Individualized
Education Plan (IEP) or Section 504 Plan if appropriate
Enlist teacher help in defining and measuring daily speech goals
Consider use of daily report card
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Sample Daily Report Card (Advanced)
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Pharmacologic Treatment
Recommended when psychosocial interventions are ineffective or when symptoms are chronic and severe
First-line treatment = Selective Serotonin Reuptake Inhibitors Fluoxetine (most studied) Sertraline Paroxetine
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Conclusions
Is SM just shyness? A formal diagnosis suggests a problem that has been
ongoing, present in numerous situations, and causing impairment
My child has SM. Is treatment needed? The majority of cases don’t resolve without
intervention. In cases when SM “goes away,” there is high risk that anxiety persists.
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Conclusions
Why are behavioral interventions recommended? SM is maintained by avoidant behavior, and data
suggests that SM can be effectively treated by learning healthy coping and approach behaviors in a gradual way.
Does the school need to be involved? School is typically where the symptoms are most severe,
so interventions need to be applied in the school. Treatment is most successful when school personnel are aware of the problem and part of the treatment collaboration.
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Conclusions
When should medication be considered? Data suggests that SSRIs are well-tolerated and
effective in pediatric populations. These medications should be considered in treatment resistant cases, when symptoms are severe, or when additional anxiety or other problems exist.
How to I effectively parent my child with SM? Be his/her biggest advocate. Understand that SM is
not a voluntary phenomenon, and that progress is gradual. Collaborate with your child to make a plan. Praise brave speech and independent behavior.
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Courtney Keeton, PhDThe Johns Hopkins University School of
MedicineDepartment of Psychiatry
Division of Child & Adolescent PsychiatryPhone: 410-614-5174
Email: [email protected]
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