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Fears and fear-related cognitions in children with selective mutism

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Abstract

Selective mutism (SM) is classified under the category of anxiety disorders in DSM-5 [1], although concrete fears that underlie the condition are not specified contrary to all other anxiety disorders. Given the lack of studies systematically investigating fears in SM, content and frequency of concrete fears as well as related cognitions have remained unclear so far. One hundred and twenty-four participants [M = 13.25 years (SD = 3.24), range 8–18 years] with SM (n = 65), social phobia (SP n = 18) or with typical development (TD n = 51) took part in an online survey. Participants with SM (n = 65) answered an open-ended question concerning fears that might cause the consistent failure to speak in select situations. Additionally, participants with SM, SP and TD completed a survey containing 34 fear-related cognitions that might occur in speech-demanding situations. Open text answers were systematically evaluated by extracting higher-order categories using a Qualitative Content Analysis. Single item scores of the survey were compared between the three groups. 59% of all spontaneously reported fears were assigned to the cluster of social fears. Other reported fears represented the categories fear of mistakes (28%), language-related fears (8%) and voice-related fears (5%). The SM- and SP group only differed regarding the cognition that one’s own voice might sound funny (SM > SP). Social fears and the fear of mistakes account for the majority of fears in SM. Therefore, future interventions should consider specifically targeting these types of fears.

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References

  1. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5). American Psychiatric Association, Washington, DC

    Book  Google Scholar 

  2. Schwartz RH, Freedy AS, Sheridan MJ (2006) Selective mutism: are primary care physicians missing the silence? Clin Pediatr 45(1):43–48. https://doi.org/10.1177/000992280604500107

    Article  Google Scholar 

  3. Muris P, Ollendick TH (2015) Children who are anxious in silence: a review on selective mutism, the new anxiety disorder in DSM-5. Clin Child Fam Psychol Rev 18(2):151–169. https://doi.org/10.1007/s10567-015-0181-y

    Article  PubMed  Google Scholar 

  4. Steinhausen H-C, Wachter M, Laimbock K et al (2006) A long-term outcome study of selective mutism in childhood. J Child Psychol Psychiatry 47(7):751–756. https://doi.org/10.1111/j.1469-7610.2005.01560.x

    Article  PubMed  Google Scholar 

  5. Remschmidt H, Poller M, Herpertz-Dahlmann B et al (2001) A follow-up study of 45 patients with elective mutism. Eur Arch Psychiatry Clin Neurosci 251(6):284–296. https://doi.org/10.1007/PL00007547

    Article  CAS  PubMed  Google Scholar 

  6. Compare A, Zarbo C, Brugnera A et al (2017) Structural analyses of members’ relationships in a selective mutism family: a single case study. Adv Psychol Res 127:201–215

    Google Scholar 

  7. Capozzi F, Manti F, Di Trani M et al (2018) Children’s and parent’s psychological profiles in selective mutism and generalized anxiety disorder: a clinical study. Eur Child Adolesc Psychiatry 27(6):775–783. https://doi.org/10.1007/s00787-017-1075-y

    Article  PubMed  Google Scholar 

  8. Manassis K, Tannock R, Garland EJ et al (2007) The sounds of silence: language, cognition, and anxiety in selective mutism. J Am Acad Child Adolesc Psychiatry 46(9):1187–1195. https://doi.org/10.1097/CHI.0b013e318076b7ab

    Article  PubMed  Google Scholar 

  9. Gensthaler A, Maichrowitz V, Kaess M et al (2016) Selective mutism: the fraternal twin of childhood social phobia. Psychopathology 49(2):95–107. https://doi.org/10.1159/000444882

    Article  PubMed  Google Scholar 

  10. Dummit ES, Klein RG, Tancer NK et al (1997) Systematic assessment of 50 children with selective mutism. J Am Acad Child Adolesc Psychiatry 36(5):653–660. https://doi.org/10.1097/00004583-199705000-00016

    Article  PubMed  Google Scholar 

  11. Chavira DA, Shipon-Blum E, Hitchcock C et al (2007) Selective mutism and social anxiety disorder: all in the family? J Am Acad Child Adolesc Psychiatry 46(11):1464–1472. https://doi.org/10.1097/chi.0b013e318149366a

    Article  PubMed  Google Scholar 

  12. Bergman RL, Gonzalez A, Piacentini J et al (2013) Integrated behavior therapy for selective mutism: a randomized controlled pilot study. Behav Res Ther 51(10):680–689. https://doi.org/10.1016/j.brat.2013.07.003

    Article  PubMed  Google Scholar 

  13. Stein MB, Yang B-Z, Chavira DA et al (2011) A common genetic variant in the neurexin superfamily member CNTNAP2 is associated with increased risk for selective mutism and social anxiety-related traits. Biol Psychiatry 69(9):825–831. https://doi.org/10.1016/j.biopsych.2010.11.008

    Article  CAS  PubMed  Google Scholar 

  14. Muris P, Hendriks E, Bot S (2016) Children of few words: relations among selective mutism, behavioral inhibition, and (social) anxiety symptoms in 3- to 6-year-olds. Child Psychiatry Hum Dev 47(1):94–101. https://doi.org/10.1007/s10578-015-0547-x

    Article  PubMed  Google Scholar 

  15. Gensthaler A, Khalaf S, Ligges M et al (2016) Selective mutism and temperament: the silence and behavioral inhibition to the unfamiliar. Eur Child Adolesc Psychiatry 25(10):1113–1120. https://doi.org/10.1007/s00787-016-0835-4

    Article  PubMed  Google Scholar 

  16. Young BJ, Bunnell BE, Beidel DC (2012) Evaluation of children with selective mutism and social phobia: a comparison of psychological and psychophysiological arousal. Behav Modif 36(4):525–544. https://doi.org/10.1177/0145445512443980

    Article  PubMed  Google Scholar 

  17. Scott S, Beidel DC (2011) Selective mutism: an update and suggestions for future research. Curr Psychiatry Rep 13(4):251–257. https://doi.org/10.1007/s11920-011-0201-7

    Article  PubMed  Google Scholar 

  18. Østergaard KR (2018) Treatment of selective mutism based on cognitive behavioural therapy, psychopharmacology and combination therapy—a systematic review. Nord J Psychiatry 72(4):240–250. https://doi.org/10.1080/08039488.2018.1439530

    Article  PubMed  Google Scholar 

  19. Zakszeski BN, DuPaul GJ (2017) Reinforce, shape, expose, and fade: a review of treatments for selective mutism (2005–2015). Sch Ment Health 9(1):1–15. https://doi.org/10.1007/s12310-016-9198-8

    Article  Google Scholar 

  20. Cohan SL, Chavira DA, Stein MB (2006) Practitioner review: psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 1990–2005. J Child Psychol Psychiatry 47(11):1085–1097. https://doi.org/10.1111/j.1469-7610.2006.01662.x

    Article  PubMed  Google Scholar 

  21. Kaczkurkin AN, Foa EB (2015) Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues Clin Neurosci 17(3):337–346

    PubMed  PubMed Central  Google Scholar 

  22. Seligman LD, Ollendick TH (2011) Cognitive-behavioral therapy for anxiety disorders in youth. Child Adolesc Psychiatr Clin N Am 20(2):217–238. https://doi.org/10.1016/j.chc.2011.01.003

    Article  PubMed  PubMed Central  Google Scholar 

  23. Colonnesi C, Nikolić M, Vente W et al (2017) Social anxiety symptoms in young children: investigating the interplay of theory of mind and expressions of shyness. J Abnorm Child Psychol 45(5):997–1011. https://doi.org/10.1007/s10802-016-0206-0

    Article  PubMed  Google Scholar 

  24. Beidel DC, Turner SM, Morris TL (1999) Psychopathology of childhood social phobia. J Am Acad Child Adolesc Psychiatry 38(6):643–650. https://doi.org/10.1097/00004583-199906000-00010

    Article  CAS  PubMed  Google Scholar 

  25. Morrison AS, Heimberg RG (2013) Social anxiety and social anxiety disorder. Annu Rev Clin Psychol 9:249–274. https://doi.org/10.1146/annurev-clinpsy-050212-185631

    Article  PubMed  Google Scholar 

  26. Rapee RM, Heimberg RG (1997) A cognitive-behavioral model of anxiety in social phobia. Behav Res Ther 35(8):741–756

    Article  CAS  Google Scholar 

  27. Cox BJ, Clara IP, Sareen J et al (2008) The structure of feared social situations among individuals with a lifetime diagnosis of social anxiety disorder in two independent nationally representative mental health surveys. Behav Res Ther 46(4):477–486. https://doi.org/10.1016/j.brat.2008.01.011

    Article  PubMed  Google Scholar 

  28. Bögels SM, Alden L, Beidel DC et al (2010) Social anxiety disorder: questions and answers for the DSM-V. Depress Anxiety 27(2):168–189. https://doi.org/10.1002/da.20670

    Article  PubMed  Google Scholar 

  29. Yeganeh R, Beidel DC, Turner SM (2006) Selective mutism: more than social anxiety? Depress Anxiety 23(3):117–123. https://doi.org/10.1002/da.20139

    Article  PubMed  Google Scholar 

  30. Manassis K, Fung D, Tannock R et al (2003) Characterizing selective mutism: is it more than social anxiety? Depress Anxiety 18(3):153–161. https://doi.org/10.1002/da.10125

    Article  PubMed  Google Scholar 

  31. Bergman RL, Piacentini J, McCracken JT (2002) Prevalence and description of selective mutism in a school-based sample. J Am Acad Child Adolesc Psychiatry 41(8):938–946. https://doi.org/10.1097/00004583-200208000-00012

    Article  PubMed  Google Scholar 

  32. Johnson M, Wintgens A (2017) The selective mutism resource manual. Routledge, Milton

    Book  Google Scholar 

  33. Omdal H, Galloway D (2008) Could selective mutism be re-conceptualised as a specific phobia of expressive speech?: an exploratory post-hoc study. Child Adolesc Ment Health 13(2):74–81. https://doi.org/10.1111/j.1475-3588.2007.00454.x

    Article  Google Scholar 

  34. Boon F (1994) The selective mutism controversy (continued). J Am Acad Child Adolesc Psychiatry 33(2):283. https://doi.org/10.1097/00004583-199402000-00023

    Article  CAS  PubMed  Google Scholar 

  35. Black B, Uhde TW (1992) Case study: elective mutism as a variant of social phobia. J Am Acad Child Adolesc Psychiatry 31(6):1090–1094. https://doi.org/10.1097/00004583-199211000-00015

    Article  CAS  PubMed  Google Scholar 

  36. Muchnik C, Ari-Even Roth D, Hildesheimer M et al (2013) Abnormalities in auditory efferent activities in children with selective mutism. Audiol Neuro-otol 18(6):353–361. https://doi.org/10.1159/000354160

    Article  Google Scholar 

  37. Crumley FE (1990) The masquerade of mutism. J Am Acad Child Adolesc Psychiatry 29(2):318–319. https://doi.org/10.1097/00004583-199003000-00031

    Article  CAS  PubMed  Google Scholar 

  38. Christon LM, Robinson EM, Arnold CC et al (2012) Modular cognitive-behavioral treatment of an adolescent female with selective mutism and social phobia. Clin Case Stud 11(6):474–491. https://doi.org/10.1177/1534650112463956

    Article  Google Scholar 

  39. Diliberto RA, Kearney CA (2016) Anxiety and oppositional behavior profiles among youth with selective mutism. J Commun Disord 59:16–23. https://doi.org/10.1016/j.jcomdis.2015.11.001

    Article  PubMed  Google Scholar 

  40. Gensthaler A, Dieter J, Raisig S et al (2018) Evaluation of a novel parent-rated scale for selective mutism. Assessment. https://doi.org/10.1177/1073191118787328

    Article  PubMed  Google Scholar 

  41. Bögels SM, Alberts M, de Jong PJ (1996) Self-consciousness, self-focused attention, blushing propensity and fear of blushing. Personal Individ Differ 21(4):573–581. https://doi.org/10.1016/0191-8869(96)00100-6

    Article  Google Scholar 

  42. Stoeber J (1995) Frost Multidimensional Perfectionism Scale-Deutsch (Unpublished)

  43. Kley H, Tuschen-Caffier B, Heinrichs N (2012) Safety behaviors, self-focused attention and negative thinking in children with social anxiety disorder, socially anxious and non-anxious children. J Behav Ther Exp Psychiatry 43(1):548–555. https://doi.org/10.1016/j.jbtep.2011.07.008

    Article  PubMed  Google Scholar 

  44. Melfsen S, Walitza S, Warnke A (2011) Psychometrische Eigenschaften und Normierung des Sozialphobie und -angstinventars für Kinder (SPAIK) an einer klinischen Stichprobe (Psychometric properties and clinical norms for the German version (SPAIK) of the Social Phobia and Anxiety Inventory for Children (SPAI-C)). Z Kinder Jugendpsychiatr Psychother 39(6):399–406. https://doi.org/10.1024/1422-4917/a000138

    Article  PubMed  Google Scholar 

  45. Mayring P (2015) Qualitative Inhaltsanalyse: Grundlagen und Techniken, 12 überarb edn. Beltz, Weinheim

    Google Scholar 

  46. Mey G, Mruck K (2010) Handbuch qualitative Forschung in der Psychologie. VS Verlag für Sozialwissenschaften, Wiesbaden

    Book  Google Scholar 

  47. Elo S, Kyngäs H (2008) The qualitative content analysis process. J Adv Nurs 62(1):107–115. https://doi.org/10.1111/j.1365-2648.2007.04569.x

    Article  PubMed  Google Scholar 

  48. Elo S, Kääriäinen M, Kanste O et al (2014) Qualitative content analysis: a focus on trustworthiness. SAGE Open 4(1):1–10. https://doi.org/10.1177/2158244014522633

    Article  Google Scholar 

  49. Hsieh H-F, Shannon SE (2005) Three approaches to qualitative content analysis. Qual Health Res 15(9):1277–1288. https://doi.org/10.1177/1049732305276687

    Article  Google Scholar 

  50. McHugh ML (2012) Interrater reliability: the kappa statistic. Biochem Med 22(3):276–282

    Article  Google Scholar 

  51. Cohan SL, Chavira DA, Shipon-Blum E et al (2008) Refining the classification of children with selective mutism: a latent profile analysis. J Clin Child Adolesc Psychol 37(4):770–784. https://doi.org/10.1080/15374410802359759

    Article  PubMed  PubMed Central  Google Scholar 

  52. Knappe S, Beesdo-Baum K, Fehm L et al (2011) Social fear and social phobia types among community youth: differential clinical features and vulnerability factors. J Psychiatr Res 45(1):111–120. https://doi.org/10.1016/j.jpsychires.2010.05.002

    Article  PubMed  Google Scholar 

  53. Oerbeck B, Stein MB, Pripp AH et al (2015) Selective mutism: follow-up study 1 year after end of treatment. Eur Child Adolesc Psychiatry 24(7):757–766. https://doi.org/10.1007/s00787-014-0620-1

    Article  PubMed  Google Scholar 

  54. Flett GL, Hewitt PL (2002) Perfectionism: theory, research, and treatment. American Psychological Association, Washington

    Book  Google Scholar 

  55. Frost RO, Marten P, Lahart C et al (1990) The dimensions of perfectionism. Cogn Ther Res 14(5):449–468. https://doi.org/10.1007/BF01172967

    Article  Google Scholar 

  56. Clark DM, Wells A (1995) A cognitive model of social phobia. In: Heimberg RG, Liebowitz MR, Hope DA et al (eds) Social phobia: diagnosis, assessment, and treatment. Guilford Press, New York, pp 69–93

    Google Scholar 

  57. Heimberg RG, Brozovich FA, Rapee RM (2010) A cognitive behavioral model of social anxiety disorder. In: Hofman SG, DiBartolo PM (eds) Social anxiety: clinical, developmental, and social perspectives. Elsevier, London, pp 395–422

    Chapter  Google Scholar 

  58. Antony MM, Purdon CL, Huta V et al (1998) Dimensions of perfectionism across the anxiety disorders. Behav Res Ther 36(12):1143–1154. https://doi.org/10.1016/S0005-7967(98)00083-7

    Article  CAS  PubMed  Google Scholar 

  59. Juster HR, Heimberg RG, Frost RO et al (1996) Social phobia and perfectionism. Personal Individ Differ 21(3):403–410. https://doi.org/10.1016/0191-8869(96)00075-X

    Article  Google Scholar 

  60. Scott JH, Yap K, Francis AJ et al (2014) Perfectionism and its relationship with anticipatory processing in social anxiety. Aust J Psychol 66(3):187–196. https://doi.org/10.1111/ajpy.12045

    Article  Google Scholar 

  61. Mitchell JH, Newall C, Broeren S et al (2013) The role of perfectionism in cognitive behaviour therapy outcomes for clinically anxious children. Behav Res Ther 51(9):547–554. https://doi.org/10.1016/j.brat.2013.05.015

    Article  PubMed  Google Scholar 

  62. Bento C, Pereira AT, Roque C et al (2017) Longitudinal effects of an intervention on perfectionism in adolescents. Psicothema 29(3):317–322. https://doi.org/10.7334/psicothema2016.223

    Article  PubMed  Google Scholar 

  63. Morris L, Lomax C (2014) Review: assessment, development, and treatment of childhood perfectionism: a systematic review. Child Adolesc Ment Health 19(4):225–234. https://doi.org/10.1111/camh.12067

    Article  Google Scholar 

  64. Beitchman JH, Wilson B, Johnson CJ et al (2001) Fourteen-year follow-up of speech/language-impaired and control children: psychiatric outcome. J Am Acad Child Adolesc Psychiatry 40(1):75–82. https://doi.org/10.1097/00004583-200101000-00019

    Article  CAS  PubMed  Google Scholar 

  65. Kristensen H (2000) Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder, and elimination disorder. J Am Acad Child Adolesc Psychiatry 39(2):249–256. https://doi.org/10.1097/00004583-200002000-00026

    Article  CAS  PubMed  Google Scholar 

  66. Steinhausen HC, Juzi C (1996) Elective mutism: an analysis of 100 cases. J Am Acad Child Adolesc Psychiatry 35(5):606–614. https://doi.org/10.1097/00004583-199605000-00015

    Article  CAS  PubMed  Google Scholar 

  67. Wong QJJ, Rapee RM (2016) The aetiology and maintenance of social anxiety disorder: a synthesis of complimentary theoretical models and formulation of a new integrated model. J Affect Disord 203:84–100. https://doi.org/10.1016/j.jad.2016.05.069

    Article  PubMed  Google Scholar 

  68. Ingram RE (1990) Self-focused attention in clinical disorders: review and a conceptual model. Psychol Bull 107(2):156–176

    Article  CAS  Google Scholar 

  69. Bögels SM, Mansell W (2004) Attention processes in the maintenance and treatment of social phobia: hypervigilance, avoidance and self-focused attention. Clin Psychol Rev 24(7):827–856. https://doi.org/10.1016/j.cpr.2004.06.005

    Article  PubMed  Google Scholar 

  70. Spurr JM, Stopa L (2002) Self-focused attention in social phobia and social anxiety. Clin Psychol Rev 22(7):947–975. https://doi.org/10.1016/S0272-7358(02)00107-1

    Article  PubMed  Google Scholar 

  71. Clark DM, McManus F (2002) Information processing in social phobia. Biol Psychiatry 51(1):92–100. https://doi.org/10.1016/S0006-3223(01)01296-3

    Article  PubMed  Google Scholar 

  72. Blote AW, Miers AC, Heyne DA et al (2014) The relation between social anxiety and audience perception: examining Clark and Wells’ (1995) model among adolescents. Behav Cogn Psychother 42(5):555–567. https://doi.org/10.1017/S1352465813000271

    Article  PubMed  Google Scholar 

  73. Eldar S, Apter A, Lotan D et al (2012) Attention bias modification treatment for pediatric anxiety disorders: a randomized controlled trial. Am J Psychiatry 169(2):213–220. https://doi.org/10.1176/appi.ajp.2011.11060886

    Article  PubMed  PubMed Central  Google Scholar 

  74. Fung DSS, Manassis K, Kenny A et al (2002) Web-based CBT for selective mutism. J Am Acad Child Adolesc Psychiatry 41(2):112–113. https://doi.org/10.1097/00004583-200202000-00003

    Article  PubMed  Google Scholar 

  75. Aydin A, Tekinsav-Sütçü S, Sorias O (2010) Evaluation of the effectiveness of a cognitive-behavioral therapy program for alleviating the symptoms of social anxiety in adolescents. Turk Psikiyatri Derg 21(1):1–11

    Google Scholar 

  76. Keeton CP, Crosby Budinger M (2012) Social phobia and selective mutism. Child Adolesc Psychiatr Clin N Am 21(3):621–641. https://doi.org/10.1016/j.chc.2012.05.009

    Article  PubMed  Google Scholar 

  77. Bunnell BE, Mesa F, Beidel DC (2018) A two-session hierarchy for shaping successive approximations of speech in selective mutism: pilot study of mobile apps and mechanisms of behavior change. Behav Ther 49(6):966–980. https://doi.org/10.1016/j.beth.2018.02.003

    Article  PubMed  Google Scholar 

  78. Leigh E, Clark DM (2018) Understanding social anxiety disorder in adolescents and improving treatment outcomes: applying the cognitive model of Clark and Wells (1995). Clin Child Fam Psychol Rev 21(3):388–414. https://doi.org/10.1007/s10567-018-0258-5

    Article  PubMed  PubMed Central  Google Scholar 

  79. Parr CJ, Cartwright-Hatton S (2009) Social anxiety in adolescents: the effect of video feedback on anxiety and the self-evaluation of performance. Clin Psychol Psychother 16(1):46–54. https://doi.org/10.1002/cpp.599

    Article  PubMed  Google Scholar 

  80. Ebert DD, van Daele T, Nordgreen T et al (2018) Internet- and mobile-based psychological interventions: applications, efficacy, and potential for improving mental health. Eur Psychol 23(2):167–187. https://doi.org/10.1027/1016-9040/a000318

    Article  Google Scholar 

  81. Bergman RL, Gonzalez A, Piacentini J et al (2013) Integrated behavior therapy for selective mutism: a randomized controlled pilot study. Behav Res Ther 51(10):680–689. https://doi.org/10.1016/j.brat.2013.07.003

    Article  PubMed  Google Scholar 

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  1. Department of Special Needs Educational and Clinical Child and Adolescent Psychology, Justus-Liebig-University of Giessen, Otto-Behaghel-Straße 10c, 35394, Giessen, Germany

    Felix Vogel, Julia Stahl & Christina Schwenck

  2. Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Frankfurt am Main, Frankfurt, Germany

    Angelika Gensthaler

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Vogel, F., Gensthaler, A., Stahl, J. et al. Fears and fear-related cognitions in children with selective mutism. Eur Child Adolesc Psychiatry 28, 1169–1181 (2019). https://doi.org/10.1007/s00787-019-01281-0

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