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Selective mutism

Selective mutism


Selective mutism is a childhood disorder in which a child does not speak in some social situations although he or she is able to talk normally at other times.


Selective mutism was first described in the 1870s, at which time it was called "aphasia voluntaria." This name shows that the absence of speech was considered to be under the control of the child's will. In 1934 the disorder began to be called selective mutism, a name that still implied purposefulness on the part of the silent child. In the 1994 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ) the disorder was renamed selective mutism. This name is considered preferable because it suggests that the child is mute only in certain situations, without the implication that the child remains silent on purpose.

Selective mutism is characterized by a child's inability to speak in one or more types of social situation, although the child is developmentally advanced to the point that speech is possible. The child speaks proficiently in at least one setting, most often at home with one or both parents, and sometimes with siblings or extended family members. Some children also speak to certain friends or to adults that are not related to them, but this variant of selective mutism is somewhat less common.

The most common place for children to exhibit mute behavior is in the classroom, so that the disorder is often first noticed by teachers. Because of this characteristic, selective mutism is most frequently diagnosed in children of preschool age through second grade. As the expectation of speech becomes more evident, selective mutism can have more pronounced negative effects on academic performance. Children who do not talk in classroom settings or other social situations because the language of instruction is not their first tongue are not considered to have the disorder of selective mutism.

Causes and symptoms

The symptoms of selective mutism are fairly obvious. The child does not talk in one or more social situations in which speech is commonly expected and would facilitate understanding. Some children with selective mutism do not communicate in any way in certain settings, and act generally shy and withdrawn. The disorder is also often associated with crying, clinging to the parent, and other signs of social anxiety. Other children with the disorder, however, may smile, gesture, nod, and even giggle, although they do not talk.

Consensus regarding the most common causes of selective mutism has changed significantly over time. When the disorder was first studied, and for many years thereafter, it was thought to be caused by severe trauma in early childhood. Some of these causative traumas were thought to include rape, molestation, incest, severe physical or emotional abuse , and similar experiences. In addition, many researchers attributed selective mutism to family dynamics that included an overprotective mother and an abnormally strict or very distant father. As of 2002, these factors have not been completely eliminated as causes of selective mutism in most cases, but it is generally agreed that they are not the most common causes.

Instead, selective mutism is frequently attributed at present to high levels of social anxiety in children and not to traumatic events in their early years. Children with selective mutism have been found to be more timid and shy than most children in social situations, and to exhibit signs of depression, obsessive-compulsive disorder , and anxiety disorders. Some children have been reported to dislike speaking because they are uncomfortable with the sound of their own voice or because they think their voice sounds abnormal.

Many links have also been found between selective mutism and speech development problems. Language reception problems have also been documented in selectively mute children. Although there is no evidence indicating that selective mutism is the direct result of any of these difficulties in language development, possible connections are being explored.


Selective mutism is generally considered a rare disorder. It is found in about 1% of patients in mental health settings, but it occurs in only about 0.01% of the general United States population. Some researchers maintain, however, that selective mutism occurs more frequently than these data suggest. There may be many unreported cases of selective mutism that resolve with time and require no intervention .

In terms of age grouping, selective mutism may appear at the very beginning of a child's social experience or may begin in later childhood. Some cases have been recorded in which selective mutism does not begin until high school. Onset in late adolescence is unusual, however; the most common age of onset for the disorder is the early elementary school years.

Selective mutism is often associated with social phobia in adult life. Children with selective mutism disorder may be more likely as adults to have a high level of social anxiety even if they do not meet the diagnostic criteria for social phobia. The disorder appears to run in families. Children whose parents are anxious in social settings, were exceptionally timid as children, or suffered from selective mutism themselves in childhood, are at greater risk for developing selective mutism.


The criteria for diagnosing selective mutism disorder given by the reference manual, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR ) include the failure to speak in some social situations even though the child may talk at other times. This criterion is not met if the child does not speak at all in any situation.

The child's inability to talk must interfere with the achievement of such relevant goals as schoolwork, play with friends, or communication of needs. In addition, the lack of speech must persist for at least one month. The first month of school should not be included in this measurement because many children are shy and unwilling to talk freely until they feel comfortable with their new teacher, classmates, and surroundings.

Furthermore, the child's lack of speech cannot be attributed to unfamiliarity with the language they must use in school or social settings. The diagnosis of selective mutism does not apply to children from immigrant families who may not feel comfortable conversing in a second language. Moreover, the child's inability to talk cannot be attributed to stuttering or similar speech disorders, which may make the child uncomfortable because they are aware that their speech sounds different from the speech of their peers. The lack of speech also must not be attributable to schizophrenia , autism , or other mental health disorders.

The disorder of selective mutism is usually noticed first by parents or teachers of affected children. It is often hard for doctors to diagnose selective mutism because it is unlikely that the child in question will talk to them. Therefore it may be difficult for a general practitioner to assess the existence of any underlying language or developmental problems that may be either causing or exacerbating the disorder. Tests that evaluate mental development without verbal responses from the patient may be used successfully to evaluate children with selective mutism.

There are also ways to test the child's speech development in the situations in which he or she does talk. One method involves interviews with the parents or whomever the child does speak to on a regular basis. This method can be fairly subjective, however. It is more useful for the doctor to obtain a tape or video recording of the child talking in a situation in which he or she feels comfortable. The child's hearing should be checked, as speech problems are often related to hearing disorders. Observing the child at play activities or asking him or her to draw pictures offer other effective ways to determine the child's reactions in social situations.


A number of different approaches have been used in attempts to treat selective mutism. Recent opinion has moved away from the idea that it is caused by a trauma, and attempts to treat it have followed accordingly. The factors that are most intensively studied at present are underlying anxiety problems. In the few cases in which an underlying trauma is discovered to be the source of the problem, counseling to help treat the underlying problems is recommended. Treatments of any kind are generally found to be more effective when the family of the child is involved in decisions about his or her treatment.

Behavior modification

Selective mutism can be treated by using a reinforcement approach. This method gives positive rewards to the child in the form of praise, treats, privileges, or anything else that the child values. In general rewards are given for speech, and withheld for silence. The use of punishments alongside the rewards is not generally recommended because it would place more stress on children who are already severely anxious. The positive reinforcement technique is generally found to be atleast partially successful in most cases.

Another technique for modifying behavior in children with selective mutism is known as stimulus fading. This technique sets goals of increasing difficulty for the child to meet. For example, the child might be encouraged to start talking by whispering, then work up gradually to talking at full volume. Alternately, the child could start by talking to one person who is not a family member and gradually add names until he or she feels comfortable talking to more than one person at a time. Stimulus fading has been found to be particularly effective when it is used in conjunction with positive reinforcement techniques.

Treatment with medications

In some cases, selective mutism is treatable with medication. Fluoxetine (Prozac), which is one of the selective serotonin reuptake inhibitors (SSRIs) is the drug that has been studied most often as a treatment for selective mutism. Treatment with medication is more successful in younger children. Overall, fluoxetine has been found to reduce the symptoms of selective mutism in about three-fourths of children. Other drugs used to treat anxiety and social phobia disorders may also be effective in certain cases.


Selective mutism is frequently treatable, in that many cases of the disorder are thought to resolve on their own. Sometimes reported cases do resolve with time, although treatment can be very effective. There is little information about the long-term outcome of selective mutism. Researchers have noted that while many children with the disorder do show improvement in speech, their anxiety in social situations persists.



American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington DC: American Psychiatric Association, 2000.

Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry. 7th edition, vol.2. Philadelphia: Lippincott Williams and Wilkins, 2000.


Dow, Sara P., and others. "Practical Guidelines for the Assessment and Treatment of Selective Mutism." Journal of the American Academy of Child and Adolescent Psychiatry 34 no. 7 (July 1995): 836-847.

Dummit, Steven E. III, and others. "Fluoxetine treatment of children with selective mutism: an open trial." Journal of the American Academy of Child and Adolescent Psychiatry 35 no. 5 (May 1996): 615-622.

Joseph, Paul R. "Selective MutismThe Child Who Doesn't Speak at School." Pediatrics 104, no. 2 (August 1999):308.

Stein, Martin T., Isabelle Rapin, and Diane Yapko. "Selective Mutism." Journal of Developmental & Behavioral Pediatrics 22, no. 2 (April 2001): S123.


Selective Mutism GroupA Division of Childhood Anxiety Network Inc. <>.

Tish Davidson, A.M.

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Selective Mutism

Selective Mutism

What Is Selective Mutism?

What Causes Selective Mutism?

What Are the Symptoms of Selective Mutism?

How Is Selective Mutism Diagnosed?

How Is Selective Mutism Treated?


Selective mutism (se-LEK-tiv MU-ti-zum) is a condition in which children feel so inhibited and anxious that they do not speak in particular situations, most commonly in school. Children with selective mutism are capable of speaking and communicating normally, and do so in other situations, for example, at home.


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Anxiety disorders

Elective mutism

When Brandon first started kindergarten, his teacher just thought he was a very quiet boy, that he would come out of his shell in a week or two. As the weeks passed into months, though, Brandon still never spoke a word at school, even when the teacher called on him. Sometimes if he needed something, he would point or gesture, but he would never speak. His teacher was concerned, and when she called his parents, they told her that Brandon spoke easily at home, and that he had always been a little shy around others. It was clear that Brandons problem was more than normal shyness. Since it was interfering with his ability to participate in class and on the playground, Brandons parents took him to a mental health professional, who diagnosed his problem as selective mutism.

What Is Selective Mutism?

Selective mutism is a condition in which children feel anxious and inhibited and do not speak in certain situations. Children with selective mutism are capable of speaking normally, and do so in other situations where they feel more comfortable. These children often talk normally at home, but they may completely stop talking around teachers, other children, or other adults. Their behavior gets in the way of making friends and doing well in school.

Selective mutism, once thought to be quite rare, is beginning to be more widely recognized. It used to be called elective mutism, because it was thought that children were purposely choosing not to talk. It was sometimes thought that a childs refusal to speak was a way to rebel against adults, or a sign of anger. It affects at least 1 in 100 school-age children. It usually begins before age 5, but it may not cause problems until children start school. The condition may last for just a few months, but in some cases, if left untreated, selective mutism can last for years. Some experts believe that untreated selective mutism in children leads to social anxiety disorder in their adult years. Experts now believe that selective mutism is an extreme form of social anxiety in a child. Social anxiety is an intense, lasting fear or extreme discomfort in social situations, and usually leads to avoidance of many social situations. With selective mutism, children seem to feel so self-consious or anxious in certain situations that they avoid talking altogether.

What Causes Selective Mutism?

There is no single cause of selective mutism. As with other forms of anxiety, some children may be more likely to have this problem if anxiety or extreme shyness runs in the family, or if they are born with a shy nature. Beyond genetics, in some families where adults are anxious, children may learn to feel socially anxious by watching the way adults react and behave. Upsetting or stressful events such as divorce, the death of a loved one, or frequent moves may trigger selective mutism in a child who is prone to anxiety.

What Are the Symptoms of Selective Mutism?

Many children are shy for a while when they first start kindergarten, but most eventually become comfortable in school, make friends, and talk to the teacher. For those with selective mutism, silence continues and lasts for a month or longer. Some children with selective mutism make gestures, nod, or write notes to communicate. Others use one-syllable words or whispers. Many children with selective mutism are very shy and fearful and may have nervous habits, such as biting their nails. They may cling to their parents and sulk around strangers but might throw temper tantrums and be stubborn and demanding at home. When pushed to speak, they may become stubborn in their refusal. It is sometimes hard for adults to understand that fear, not stubbornness, is at the root of selective mutism, and that children with this condition experience speaking as risky, scary, or dangerous. Understood in this way, it is possible to see a childs stubborn refusal to speak when forced as a strong, but misguided, attempt at self-protection.

How Is Selective Mutism Diagnosed?

Some children with selective mutism will speak to a mental health professional, but others will not. Even if children are silent, though, a skilled professional therapist still can learn a lot by watching how they behave. The therapist also can talk to parents and teachers to find out more about the problem and possible factors that contribute to it. In addition, a number of tests may be needed to exclude other possible causes for failing to speak. These include special medical tests to rule out brain damage, intelligence and academic tests to rule out learning problems, speech and language tests to rule out communication disorders*, and hearing tests to rule out hearing loss.

* communication disorders
affect a persons ability to use or understand speech and language.

How Is Selective Mutism Treated?

Most children who have selective mutism want to feel comfortable talking. Though they resist efforts to help them talk at first, therapy can be very helpful in treating this problem. The most common treatment for selective mutism is behavioral (bee-HAY-vyor-al) therapy, which helps people gradually change specific, unwanted types of behavior. For example, after the therapist helps the child to feel comfortable, the child might be rewarded for speaking softly and clearly into a tape recorder. Once they have succeeded at this several times, they can move on to being rewarded for speaking to one child at school. Children who are selectively mute may speak to specific children. They then might be invited to participate in a group with the children the selectively mute child speaks to.

Often family therapy is added, which helps identify and change behavior patterns within the family that may play a role in maintaining mutism. When a child has selective mutism, it is common for the family members to speak for the child. While they begin to do this out of love and concern and the desire to be helpful, these patterns must be discontinued to help motivate a reluctant child to begin to speak for herself. Play therapy and drawing are often used to help these children to express their feelings and worries. In addition, some children with selective mutism are prescribed medications used for treating anxiety. These medications help lessen the anxiety that plays an important role in the selectively mute childs behavior, allowing the child to take the risks involved in talking out loud.

See also

Anxiety and Anxiety Disorders

Social Anxiety Disorder



Selective Mutism Group, 30 South J Street, 3A, Lake Worth, FL 33460. This organization provides online support for the parents of children with selective mutism.

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