Guidelines for the Assessment and Treatment of Selective Mutism
SARA P. DOW, B.A., BARBARA. C. SONIES, PH_D.. DONNA SCHEIB, M.S_C.CC.lS.P-, SHARON E. MOSS, PH.D" AND HENRlETT A L. LgONARD, M.D.
Objective: To provide practical guidelines for the assessment and treatment of children with selective mutism, in light of the recent hypotnesis that selective mutism might be best conceptualized as a childhood anxiety disorder. Method: An extensive literature review was completed on the phenomenology, evaluation, and treatment of children with selective mutism. Additional recommendations were based on clinical experience from the authors' selective mutism clinic. Results: No systematic studies of the phenomenology of children with selective mutism were found. Reports described diverse and primarily noncontrolled treatment approaches with minimal follow-up information. Assessment and treatment options for selective mutism are presented, based on new hypotheses that focus on the anxiety component of this disorder. Ongoing research suggests a role for behavior modification and pharmacotherapy similar to the approaches used for adults with social phobia. Conclusion: Selectively mute children deserve a comprehensive evaluation to identify primary and comorbid problems that might require treatment. A school-based multidisciplinary individualized treatment plan is recommended, involving the combined effort of teachers, clinicians, and parents with home- and clinic- based interventions (individual and family psychotherapy, pharmacotherapy) as required. J. Am. Acad. Child Ado/esc. Psychiatry, 1995, 34, 7:836-846. Key Words: selective (or elective) mutism, child, anxiety disorders, social phobia, pharmacotherapy, speech and language.
Selective mutism is a disorder of childhood character- ized by the total lack of speech in at [east one specific siruacion (usually the classroom), despite the ability to speak in other situations. Recently there has been a shift in the etiological views on selective mutism, deemphasizing psychodynamic factors and instead fo- cusing on biologically mediated temperamental and anxiety components (Black and Uhde, 1992; Crumley, 1990; Golwyn and Weinstock, 1990; Leonard and .
Topol, 1993). Reports in the literature, in addition to our clinical work, suggest that selective mutism may
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}vfs. Dow and Dr. Leonard are in rh, Sterian on Blhat·ioraL Pediatrics, Child Psychwrry Branch. National lnstitute of Mmtal Health. Ms. Schdb, Dr. Moss, and Dr. Sonia (Section ChiifJ art in rh( Speech and Lznguagt PathofIJgy Section, Departmmt of RthabiLitation Mtdicin(, Clinical Center. National Institutes of Health. Reprint mflltJU to Dr. Leonard; Section on Behavioral Pediatria, Child Psychi4.rry/NIMH, Building 10. Room 6N240, 10 Cmm' Drive MSC 1600. Btfh(f(ia, MD 20892-1600. ' 0890-8567/95J3407-D836S03.00/0© 1995 bv the American Acadernv of Child rod Adolescenr Psychiarry.· .
be the manifestation of a shy, inhibited temperament, most likely modulated by psychodynamic _and psy- chosocial issues and in some cases associated with neuropsychological delays (developmental delays, speech and language disabilities, or difficulry processing social cues) (Fig. 1). Although systematic study of this hypothesis is still needed, cognitive-behavioral treat- ment interventions, in addition to...
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