Professional Documents
Culture Documents
Clinical Implications
Limitations
· As the study was not randomized, there might have been economic, educational, or
severity-related selection biases among families electing to have various
interventions.
· The small sample size and lack of a nonintervention control group limit our ability to
draw definite conclusions.
· Improvement ratings by teacher report (in addition to mothers and clinicians) would
have strengthened the findings.
espite using normal speech (usually at home), children both the total score and the sum of the 2 nonfamilial environ-
D with SM fail to speak in selective environments (often at
school).1 Treatment of this potentially debilitating condition
ment scores were related to treatment, as children with SM
often speak normally at home. Treatment was determined
has received limited research attention, partly owing to its rar- largely by parental preference, with no attempt to assign chil-
ity (prevalence is estimated at 0.7%2). Findings suggest that dren to particular treatments apart from providing school
SM may be related to social phobia,3 with anxiolytic medica- consultations to all participants. Monitoring of treatment was
tions and psychotherapy having been examined. Medication left to clinicians’ judgment, as would be the case in commu-
studies included a randomized controlled trial of fluoxetine4 nity settings.
with some open trials of other serotonergic medications, and
numerous case reports. Follow-up intervals were relatively Results
brief (9 to 12 weeks), and it is unclear whether samples in Among the original 20 subjects seen, 17 returned for a 6- to
these trials were representative of children with SM in the 8-month follow-up appointment (85%) with at least one par-
general population. Psychotherapy studies consist mostly of ent. All mothers attended, so results are by maternal report.
case reports, with only one small controlled trial of behav- Nonparticipants did not differ from participants in demo-
ioural intervention5 and no gold standard therapy in the field. graphic characteristics or initial CGAS or SMQ scores, sug-
No studies have contrasted outcomes for different treatments. gesting the follow-up sample was representative of the
Given the high persistence rates of SM and associated mor- original. Similarly, demographic characteristics, initial
bidity,6 comparative trials are needed to guide clinicians’ CGAS, and initial SMQ did not differ for medicated, com-
interventions and improve the chances of returning such chil- pared with unmedicated children, nor for those who did,
dren to a normative developmental course. This pilot study is a compared with those who did not receive psychotherapy. The
first step toward such trials. 17 participants had a mean age of 7.83 (SD 1.28) years at ini-
tial assessment (that is, 8.33 years at follow-up). Twelve were
Methods female and 5 were male, showing a trend towards female pre-
In our study, 20 children with SM and their parents, partici- ponderance (÷2 = 2.88, P = 0.09). All but one initially met cri-
pants in a study of cognitive and linguistic abilities in SM at a teria for both SM and social phobia on parental interview
children’s hospital, were invited to return 6 to 8 months after (Anxiety Disorders Interview Schedule). The remaining
their initial research assessment.7 When assessed initially, all child only met criteria for SM.
children had been mute for at least one full school year. All Diagnoses remained stable over 6 to 8 months, with the
procedures were approved by the Research Ethics Board of exception of one child who no longer met criteria for SM at
the Hospital for Sick Children in Toronto, and parents pro- follow-up.
vided written informed consent. Verbal assent was obtained
Significant changes in CGAS or SMQ over 6 to 8 months
from children whenever possible.
were examined for all 17 children using paired sample t tests
At follow-up, treatment received was determined and out- (Table 1). Significant improvements were found in the
comes were measured using brief parent-report question- CGAS (t = 3.49, P = 0.003), the total SMQ (t = 3.45, P =
naires (SMQ8 and CGI9) and a semi-structured parent 0.004), and the SMQ school and other scales (t = 3.40, P =
interview (Anxiety Disorders Interview Schedule10) adminis- 0.004). Significance was maintained when applying the
tered by a trained child psychiatrist blind to treatment status. Bonferroni correction for multiple t tests. Global improve-
This psychiatrist also completed the CGAS11 based on the ment ratings by mothers averaged 3 for the sample, corre-
interview and clinical notes on current functioning for each sponding to improved.
child. The SMQ ascertains quantity of speech in 3 environ-
All children’s schools received monthly telephone consulta-
ments: family, school, and other social situations, and has
tions from an experienced member of the clinical research
been used in numerous research studies of SM. In this study,
team. All children were initially medication-free, but were
offered treatment with an SSRI at time of assessment. Ten of
Abbreviations used in this article the 17 families agreed to such treatment. Eight children
received a liquid preparation of fluoxetine, and 2 received
CGAS Children’s Global Assessment Scale
sertraline. Dosage was titrated upwards gradually depending
CGI Clinical Global Improvement Rating
on response, with final dosages of 10 to 25 mg of fluoxetine
SM selective mutism
and 25 to 50 mg sertraline. Three families admitted providing
SMQ Selective Mutism Questionnaire the medication inconsistently to their child (stopping it with-
SSRI selective serotonin reuptake inhibitor out the physician’s knowledge in one case), though no formal
measures of compliance were done. Insomnia was reported
The Canadian Journal of Psychiatry, Vol 53, No 10, October 2008 W 701
Brief Communication
CGAS (initial) 47.94 (5.40) 46.20 (4.94) 50.43 (5.38) 49.20 (6.23) 46.14 (3.62)
CGAS (6 months) 57.82(8.38)b 62.00 (8.14)b 51.86 (4.18) 54.80 (7.25) 62.14 (8.45)
Total SMQ (initial) 6.25 (1.24) 5.95 (1.36) 6.74 (0.89) 6.65 (1.09) 5.57 (1.27)
Total SMQ (6 to 8 months) 7.43 (1.51)b 7.67 (1.70) 7.09 (1.25) 7.57 (1.51) 7.24 (1.65)
SMQ school and other 3.08 (0.81) 2.80 (0.74) 3.60 (0.71) 3.43 (0.82) 2.47 (0.19)
(initial)
SMQ school and other 4.06 (1.13)b 4.24 (1.25)c 3.79 (0.97) 4.17 (1.22) 3.90 (1.08)
(6 to 8 months)
CGI 2.94 (1.08) 2.50 (0.97)c 3.57 (0.98) 3.10 (0.99) 2.71 (1.25)
a
Significance indicated for whole-sample changes from baseline to 6 to 8 months.
b
P < 0.01; cP < 0.05
Résumé : Comparer les interventions pour le mutisme sélectif : une étude pilote
Objectif : Examiner le résultat en 6 à 8 mois d’une intervention médicale et non médicale auprès d’enfants souffrant de
mutisme sélectif (MS) grave.
Méthode : Des enfants souffrant de MS (n = 17) et leurs mères, vus dans une étude précédente, ont participé à des
rendez-vous de suivi avec un clinicien. Les rapports maternels présentaient : le traitement reçu, le diagnostic actuel
(selon une entrevue semi-structurée), le langage dans différents milieux, et l’amélioration générale. Un clinicien
indépendant cotait aussi le fonctionnement global.
Résultats : Le diagnostic de MS persistait chez 16 enfants, mais une amélioration symptomatique significative était
évidente dans l’échantillon. Tous les enfants avaient reçu des consultations à l’école. Les enfants qui avaient été traités
aux inhibiteurs spécifiques du recaptage de la sérotonine (ISRS) (n = 10) présentaient une plus grande amélioration
générale, une plus grande amélioration du fonctionnement, et une plus grande amélioration du langage en dehors de la
famille que les enfants qui n’étaient pas médicamentés (n = 7). Il n’y avait pas de différence manifeste pour les enfants
qui recevaient ou ne recevaient pas d’intervention non médicale additionnelle.
Conclusions : Les résultats suggèrent le bénéfice potentiel du traitement aux ISRS pour le MS grave, mais des études
aléatoires de traitements comparés sont indiquées.
The Canadian Journal of Psychiatry, Vol 53, No 10, October 2008 W 703