Understanding Selective Mutism
COURTNEY KEETON, PHD
CLINICAL PSYCHOLOGIST
ASSISTANT PROFESSOR OF PSYCHIATRY
THE JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE
DECEMBER 3 2012
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?
C Keeton PhD
12/3/12
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

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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
Interpersonal
and
environmental
contexts
Emotions
Cognition
Physiology
Behavior
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Features of CBT
 Time-limited
 Skill-based, problem-specific, goal-oriented
 Structured (but flexible)
 Present and solution-focused
 Collaborative
 Empirically-based (data shows it works!)
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CBT for SM
Anxiety
Anxious
Beliefs
Physiology
Avoidant Behavior
Accommodation by
Others
Parenting
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CBT for SM
Avoidant
Behavior
Accommodation
by Others
Parenting
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Targeting Avoidant Behavior
 Techniques: Graduated Exposure, Shaping, Stimulus
Fading
Read short story aloud
Ask questions during “Guess Who”
Whisper counting during “Chutes & Ladders”
Mouth the names of pictures/colors during game
Show home video of self talking to doctor
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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 feedback
 Provide education
 Secure 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.
C Keeton PhD
12/3/12
Courtney Keeton, PhD
The Johns Hopkins University School of Medicine
Department of Psychiatry
Division of Child & Adolescent Psychiatry
Phone: 410-614-5174
Email: ckeeton@jhmi.edu
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