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Selective Mutism

Selective mutism is a syndrome in which there is a consistent failure to speak in social situations where speech is expected, despite speaking in other situations. The problem is most common in the child who speaks actively and well at home but who refuses to speak.

Selective mutism is a syndrome in which there is a consistent failure to speak in specific social situations where speech is expected despite speaking in other situations. Most often a young child (average age, 5 years) speaks actively and well at home but refuses to speak to the teacher.


Selective mutism is described in the DSM-IV as a syndrome with the following characteristics:

  1. Failure to speak in situations where speech is expected despite speaking.
  2. Duration must be more than 1 month.
  3. No speech problems or problem caused by a 
  4. The disturbance must interfere with education, occupation, or social communication.
  5. There is no developmental or psychiatric disorder such as autism, schizophrenia, mental retardation, or 

The syndrome was described over 100 years ago. For many years it went by the term elective mutism--however, since 1994 the syndrome has been called selective mutism. Very little about selective mutism has appeared in the pediatric literature. Only one of four major pediatric textbooks makes any reference to selective mutism. What is even more striking is that an article on selective mutism has never appeared in an American pediatric journal. The vast majority of articles on selective mutism have appeared in the psychiatric, psychologic, social work, counseling.

Until recently most articles on selective mutism were written with a psychoanalytic bias. Authors assumed physical or emotional trauma as the source of the problem and they advocated a psychoanalytic approach to therapy. In more recent years behavioral therapists have had better success as it became apparent that emotional and physical trauma do not play a big role as the cause of most cases of selective mutism. Recent studies  have suggested that biologically mediated temperament and anxiety components play the major role in the cause of selective mutism. Most experts now feel that selective mutism appears mostly in an extremely shy child with social anxiety. A family history of selective mutism, extreme shyness or anxiety disorders (social phobia, panic disorder, obsessive-compulsive disorder) may put the child at risk for the development of a similar problem. In the two families presented here shyness, social phobia, and selective mutism have occurred in close relatives.

In the past 10 years reports have explored the use of antidepressants in the therapy of selective mutism. Dummit et al have reported on a trial of fluoxetine (Prozac), a selective serotonin reuptake inhibitor (SSRI), in a group of 21 children with selective mutism. Although the trial was not controlled, the results, nevertheless, were impressive, and certainly superior to past results in the literature with a psychoanalytic.

In a 9-week trial, 16 of 21 children were improved with diminished anxiety and increased speech in public settings.

Accepted current therapy combines behavior modification, family participation, school involvement, and possible psychopharmacology in the therapy of selective mutism. It is likely that even after the mutism is cured, the child is apt to suffer significant symptoms of shyness and social anxiety into adolescence and adulthood. This would suggest that the therapist's role should not end when the child achieves speech in school. The article by Dow et al is a particularly fine summary of the current thinking on assessment and treatment of selective mutism.

As more and more children in the United States are entering preschool and nursery programs at younger ages, it is most likely that increased numbers of children with selective mutism will be uncovered. Selective mutism is no longer thought to be the rare syndrome of years past. In each of the 2 children with selective mutism described here, this syndrome was uncovered not by asking the mothers about their child's lack of speech in school but rather by the fact that the mothers volunteered information.

Many cases of selective mutism will not be uncovered unless physicians, in the pediatric history, ask specifically about speech in school. The physician seeing a schoolage child in his office who does not speak in his/her office should ask the mother specifically about the child's speech in school. Finally it should be noted that each mother chose not to pursue therapy for her child at present. In each case, this was probably attributable to a family member whose selective mutism cleared without therapy and also to the young age of the child. As these children grow older and are faced with more complex social relationships, their parents may be more apt to choose active therapy. If lack of speech in school persists past kindergarten.