A young mother brings her 5-year-old daughter to the office due to problems at school. The patient started kindergarten 2 months ago and appeared to be doing fine. Last week, the teacher called to say that the child has persistently refused to answer questions or speak to others in class since her arrival. The teacher did not report it earlier as she thought the child was undergoing an adjustment period. During playtime, she prefers to play by herself. In class she remains quiet while the other children sing songs or recite the alphabet. The mother finds this very surprising as the patient is talkative at home and plays with her siblings and neighborhood friends. In addition, the patient did not report any issues with school to her mother, saying it was "fine." She is "a little shy" at social gatherings but interacts with other kids and adults when she gets to know them. The child is able to tie her shoelaces, jump rope, and dress and feed herself. She can copy a triangle and is able to count to 10. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?

Question

A young mother brings her 5-year-old daughter to the office due to problems at school.  The patient started kindergarten 2 months ago and appeared to be doing fine.  Last week, the teacher called to say that the child has persistently refused to answer questions or speak to others in class since her arrival.  The teacher did not report it earlier as she thought the child was undergoing an adjustment period.  During playtime, she prefers to play by herself.  In class she remains quiet while the other children sing songs or recite the alphabet.  The mother finds this very surprising as the patient is talkative at home and plays with her siblings and neighborhood friends.  In addition, the patient did not report any issues with school to her mother, saying it was "fine."  She is "a little shy" at social gatherings but interacts with other kids and adults when she gets to know them.  The child is able to tie her shoelaces, jump rope, and dress and feed herself.  She can copy a triangle and is able to count to 10.  Physical examination shows no abnormalities.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This patient's refusal to speak in a specific social situation (school), in contrast to her engagement in normal communication in situations in which she feels comfortable (eg, at home with siblings, friends), is consistent with selective mutism. This diagnosis requires consistent (≥1 month) failure to talk in situations in which it is expected (eg, school) despite the patient's speaking in other situations. Refusal to speak at school can impair both academic and social development and should not be considered normal shyness (Choice B). Evaluation should rule out the impaired communication that can occur in autism spectrum disorders, childhood-onset psychosis, or pervasive communication disorders (eg, language disorder, social [pragmatic] communication disorder). Selective mutism is considered an anxiety disorder and is frequently comorbid with social anxiety disorder (SAD), in which social situations are avoided or endured with great distress due to fears of negative evaluation. Treatment options for selective mutism include cognitive-behavioral therapy with graded exposure to social situations, family therapy, and selective serotonin reuptake inhibitors. (Choice A) Adjustment disorder is not diagnosed when the symptoms meet the criteria for a more specific psychiatric disorder. This patient's consistent refusal to speak in school for ≥1 month meets criteria for selective mutism. (Choice D) Separation anxiety disorder is characterized by extreme anxiety when separated from home or loved ones and excessive worry about losing major attachment figures. This patient neither refuses to go to school nor cries on separation, which would be expected with separation anxiety. (Choice E) Children with social (pragmatic) communication disorder have difficulties with social interaction involving both verbal and nonverbal communication (eg, eye contact, body language). Impairment in communication is evident in multiple settings. (Choice F) Stranger anxiety is a normal finding that usually begins in children age 6-9 months and generally subsides by age 3. It involves anxiety and distress when encountering unfamiliar people, even in the presence of a parent. Educational objective: Children with selective mutism are verbal at home but refuse to speak in specific social settings, commonly at school. It is considered an anxiety disorder and should be treated early to prevent long-term educational and social impairment. References: Selective mutism. (http://www.ncbi.nlm.nih.gov/pubmed/26709680) Children who are anxious in silence: a review on selective mutism, the new anxiety disorder in DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/25724675)

A Young Mother Brings Her 5-Year-Old Daughter to the Office