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Key Features

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Essentials of Diagnosis
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  • Consistent failure to speak in social settings (such as school) where this is expected, despite speaking in other settings

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General Considerations
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  • More frequent in younger children

  • Symptoms may be present before 5, but usually do not lead to problems until the child enters school

  • Immigrant children or other children who initially learned one language and are expected to function in the school setting in a second language may present with selective mutism

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Clinical Findings

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Symptoms and Signs
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  • Can become angry and aggressive when facing a demand to speak

  • Usually speak with close family members and may also speak with a "best" friend

  • May be quite outgoing within this comfortable setting but are often shy outside of this setting

  • Can be comfortable with social roles that do not require verbal communication

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Differential Diagnosis
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  • Other disorders that can interfere with speech, such as autism, communication disorders, and psychotic disorders

  • Comorbid anxiety disorders, such as social anxiety disorder, separation anxiety, and specific phobia

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Diagnosis

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  • Screening for selective mutism is useful since families may not be aware of the problem, or may not appreciate that it is interfering with function at school

  • To meet criteria for selective mutism, symptoms must interfere with function in school, work, or social communication, and must last longer than 1 month, not including the first month of school

  • Symptoms cannot be due to autism, a communication disorder or psychotic disorders

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Treatment

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  • Usually begins with psychoeducation

  • Children can be difficult to engage due to their shyness, so clinicians must be adept at using both verbal and nonverbal methods to form an alliance with the child

  • Cognitive-behavior therapy with exposure aimed at increasing verbal interactions can be very successful

  • Patients with more severe symptoms, or symptoms that do not respond to therapy, may benefit from a selective serotonin reuptake inhibitor

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Outcome

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Prognosis
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  • Recognition and treatment is critical as the longer a child avoids verbal communication in settings outside of the family, the more entrenched this behavior becomes

  • Children with untreated selective mutism are at risk for depression, and social anxiety disorder and substance abuse as adolescents

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References

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American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, American Psychiatric Association; 2013.
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Beesdo-Baum  K, Knappe  S: Developmental epidemiology of anxiety disorder. Child Adolesc Psychiatric Clin N Am 2012;21:457–478
[PubMed: 22800989] .
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Ghandhi  B, Cheek  S, Campo  JV: Anxiety in the pediatric medical setting. Child Adolesc Psychiatric Clin N Am 2012;21:643–653
[PubMed: 22800999] .
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Ginsberg  GS, Kendall  PC, Sakolsky  D  et al: Remission after acute treatment ...

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