SPECIAL ARTICLE

Practical Guidelines for the Assessment and Treatment

of Selective Mutism
SARA P. DOW, B.A., BARBARA C. SaNIES, PH.D., DONNA SCHEIB, [Link].P.,
SHARON E. MOSS, PH.D., AND HENRIETTA L. LEONARD, M.D.

ABSTRACT
Objective: To provide practical guidelines for the assessment and treatment of children with selective mutism, in light
of the recent hypothesis that selective mutism might be best conceptualized as a childhood anxiety disorder. Method:
An extensive literature review was completed on the phenomenology, evaluation, and treatment of children with selective
mutism. Additional recommendations were based on clinical experience from the authors' selective mutism clinic.
Results: No systematic studies of the phenomenology of children with selective mutism were found. Reports described
diverse and primarilynoncontrolled treatment approaches with minimal follow-up information. Assessment and treatment
options for selective mutism are presented, based on new hypotheses that focus on the anxiety component of this
disorder. Ongoing research suggests a role for behavior modification and pharmacotherapy similar to the approaches
used for adults with social phobia. Conclusion: Selectively mute children deserve a comprehensive evaluation to
identify primary and comorbid problems that might require treatment. A school-based multidisciplinary individualized
treatment plan is recommended, involving the combined effort of teachers, clinicians, and parents with home- and clinic-
based interventions (individual and family psychotherapy, pharmacotherapy) as required. J. Am. Acad. Child Ado/esc.
Psychiatry, 1995, 34, 7:836-846. Key Words: selective (or elective) mutism, child, anxiety disorders, social phobia,
pharmacotherapy, speech and language.

Selective mutism is a disorder of childhood character- be the manifestation of a shy, inhibited temperament,
ized by the total lack of speech in at least one specific most likely modulated by psychodynamic and psy-
situation (usually the classroom), despite the ability to chosocial issues and in some cases associated with
speak in other situations. Recently there has been a neuropsychological delays (developmental delays,
shift in the etiological views on selective mutism, speech and language disabilities, or difficulty processing
deemphasizing psychodynamic factors and instead fo- social cues) (Fig. 1). Although systematic study of this
cusing on biologically mediated temperamental and hypothesis is still needed, cognitive-behavioral treat-
anxiety components (Black and Uhde, 1992; Crumley, ment interventions, in addition to pharmacotherapy,
1990; Golwyn and Weinstock, 1990; Leonard and have become more common than traditional psychody-
Topol, 1993). Reports in the literature, in addition to namic approaches. The intent of this article was to
our clinical work, suggest that selective mutism may provide practical guidelines for the assessment and
treatment of selective mutism based on our clinical
experience along with reports from the literature.
Accepted February 17, 1995.
Ms. Dow and Dr. Leonard are in the Section on Behavioral Pediatrics, BACKGROUND
Child Psychiatry Branch, National Institute of Mental Health. Ms. Scheib,
Dr. Moss, and Dr. Sonies (Section Chief) are in the Speech and Language History and Definition
Pathology Section, Department of Rehabilitation Medicine, Clinical Center,
National Institutes of Health. In the latter part of the 19th century, Kussmaul
Reprint requests to Dr. Leonard, Section on Behavioral Pediatrics, Child (1877) described a disorder in which people would
Psychiatry/NIMH, Building 10, Room 6N240, 10 Center Drive MSC 1600,
not speak in some situations, despite having the ability
Bethesda, MD 20892-1600.
0890-8567/95/3407-0836$03.00/0©1995 by the American Academy to speak. Kussmaul named this disorder "aphasia vo-
of Child and Adolescent Psychiatry. luntaria," thereby emphasizing what he thought was

836 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:7, JULY 1995

 ASSESSMENT AND TREATMENT OF SELECTIVE MUTISM

Temperamental Psycbosocial and Differential Diagnosis

Inbibition, Sbyness Psycbodynamic
and Anxiety Factors
Since speech inhibition can be a secondary symptom
of many other psychiatric disorders (including pervasive

\~j
developmental disorder, schizophrenia, and severe men-
tal retardation), differential diagnosis for selective mut-
ism can be complex (American Psychiatric Association,
1994). When a communication disorder is present,
distinguishing between symptoms that are secondary
NOT
SPEAKING
to speech and language problems and those that are
IN suggestive of selective mutism may be even more diffi-
SOCIAL cult. Although speech and language deficits can cause
SITUATIONS speech inhibition (Lerea and Ward, 1965), several

I \
authors have reported that speech and language prob-
lems can also exist comorbidly with selective mutism
(Kolvin and Fundudis, 1981; Wilkins, 1985;
Wright, 1968).
History of Neuropsycbological
Developmental Social Cue
Delays Processing Disorder Epidemiology

Selective mutism has been described as a rare disor-

Speecb and Language der, affecting fewer than 1% of school-age children,
Learning Disabilities
but little systematic research has been done to support
Fig. 1 Factors that may influence speech and social inhibition.
this estimate. Using fairly strict diagnostic criteria,
Fundudis and colleagues (1979) identified two selec-
a voluntary decision not to speak. When Tramer (1934) tively mute children in a survey of 3,300 seven-year-
observed the same symptoms, he called the problem olds in Newcastle, u.K., a rate of 0.06%. In contrast,
"elective mutism," with the belief that these children Brown and Lloyd (1975) reported a much higher
were "electing" not to speak. The most recent edition of prevalence of 0.69% (42/6,072 children). However,
the Diagnostic and Statistic Manual ofMental Disorders this estimate was obtained after only 8 weeks of school,
(DSM-IV) (American Psychiatric Association, 1994) and 56 weeks later, the rate had fallen to 0.02% (11
has adopted a new term: "selective mutism." The 6,072 children).
change from "elective" to "selective" (implying that
the children do not speak in "select" situations) is Etiology
consistent with new theories of etiology that deempha-
Etiological explanations for selective mutism have
size oppositional behavior and instead focus more on
varied widely (Leonard and Dow, 1995). Some have
anxiety issues. The diagnosis of selective mutism, how-
explained it as a response to family neurosis, usually
ever, revolvesaround only one primary symptom: "con-
sistent failure to speak in specific social situations characterized by overprotective or domineering mothers
. .. despite speaking in other situations" (American and strict or remote fathers (Browne et al., 1963;
Psychiatric Association, 1994, p. 115). Additional crite- Meijer, 1979; Meyers, 1984; Parker et al., 1960;
ria require that the symptom last at least 1 month, Pustrom and Speers, 1964). Others have suggested
be severe enough to interfere with educational or that the symptom could be a manifestation of unre-
occupational achievement, and not be due to another solved psychodynamic conflict (Elson et al., 1965;
problem (such as insufficient knowledge of the lan- Youngerman, 1979). In addition, some have reported
guage, a communication disorder, pervasive develop- that it may develop as a reaction to trauma, such as
mental disorder, schizophrenia, or another psychotic sexual abuse or early hospitalization (MacGregor et al.,
disorder). Despite these criteria, the population of 1994). Divorce, death of a loved one, and frequent
children with selective mutism remains heterogeneous, moves have also been postulated to play a role in
which could complicate treatment recommendations. symptom development.

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:7, JULY 1995 837

DOW ET AL.

In the more recent literature, authors have noted a diagnosis is often not made until the child enters
resemblance between selectively mute children and kindergarten or first grade and verbal skills become
sociallyphobic adults (Blackand Uhde, 1992; Crumley, more essential (5 to 6 years old).
1990; Golwyn and Weinstock, 1990; Leonard and Nearly all descriptions of selectively mute children
Topol, 1993). Crumley (1990) reported the case of a in the literature have included some reference to their
29-year-old man who had been selectively mute at age shyness, inhibition, or anxiety. Some have described
8V2years. The man remembered being afraid to speak them as " ... particularly sensitive, shy, afraid of
for fear that he "might say or do the wrong thing" everything strange or new ..." (Wergeland, 1979, p.
(Crumley, 1990, p. 318). He also described experienc- 219), others called them "unduly timid and sensitive"
ing "sudden episodes of intense anxiety" and physical (Morris, 1953, p. 667), and others reported "shy,
symptoms that were suggestive of panic (shortness of timid, clinging behavior away from home" (Hayden,
breath, palpitations, dizziness) when he was placed in 1980, p. 128). One author went so far as to characterize
a situation where speech was expected. As an adult, them as not only shy, but actually "socially inept"
the patient still had anxiety in social situations and (Friedman and Karagan, 1973, p. 250). Our clinical
often would not initiate conversation for fear that he experience with selectively mute children has suggested
would "say the wrong thing and embarrass myself' that anxiety may playa much larger role than previously
(Crumley, 1990, p. 319). Crumley speculated that the acknowledged, and these reports support such a
patient's problems with social phobia might have been hypothesis.
related to his initial elective (selective) mutism A wide variety of comorbid psychiatric problems
symptoms. have been described in children with selective mutism.
Black and Uhde (1992) described a selectively mute Kolvin and Fundudis (1981) reported an increased
girl who had told her mother that she was reluctant
incidence of elimination problems (as high as 42% for
to speak because "her voice sounded funny and she
enuresis and 17% for encopresis, versus 15% and
did not want others to hear it" (Black and Uhde,
2% for controls). Others found obsessive-compulsive
1992, p. 1090). Her family psychiatric history was
features (Hayden, 1980; Kolvin and Fundudis, 1981;
remarkable for paternal public-speaking anxiety and
Wergeland, 1979), school phobia (Elson et al., 1965;
maternal childhood shyness. Boon (1994) reported the
Parker et al., 1960; Pustrom and Speers, 1964; Wright,
case of a 6-year-old girl who did not speak to adults.
1968), and depression (Wilkins, 1985).
She explained her inability to speak by saying, "my
Although there have been no reports of systematic
brain wouldn't let me; my voice sounds strange" (Boon,
speech and language assessment, several authors have
1994, p. 283). The girl's father was in treatment for
panic disorder, and her paternal grandfather had had noted speech delays or problems among selectively
an anxiety disorder. Boon (1994, p. 283) speculated mute children. Kolvin and Fundudis (1981) reported
that research on the pharmacotherapy of selective mut- that the 24 selectively mute children in their study
ism " ... likely will support the view that elective began speaking significantly later than 102 matched
mutism is an anxiety/OCD spectrum disorder." controls (27.3 months versus 21.9 months; no p value
given). In addition, half (12/24) of these same selec-
Phenomenology tively mute children had immaturities of speech at the
Several authors found selective mutism to be more time of evaluation, whereas only 9% (9/102) of the
prevalent in females than males (Hayden, 1980; Werge- normal controls had any such problems. Wilkins (1985)
land, 1979; Wilkins, 1985; Wright, 1968). However, reported that 6 (25%) of the 24 selectively mute
others found the disorder only slightly more frequent in children he studied had a delayed onset of speech and
females (Brown and Lloyd, 1975; Kolvin and Fundudis, 2 (8.3%) had speech problems at the time of evaluation,
1981), and some found no sex difference (Parker et al., while no such problems were found in any of the
1960). Onset is usually insidious, with parents reporting controls. Wright (1968) found articulation problems
that the child "has always been this way" (Hayden, in 5 (21%) of his 24 patients, one of whom was
1980; Kolvin and Fundudis, 1981; Leonard and Topol, dysarthric. Of note, these authors measured speech
1993; Wright, 1968; Wright et al., 1985), but the problems only and gave no reports of linguistic ability.

838 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 34:7. JULY 1995

 ASSESSMENT AND TREATMENT OF SELECTIVE MUTISM

Preliminary data from comprehensive speech and lan- and anxiety in social situations can be revealing. The
guage assessments ofselectively mute children evaluated child's social interaction outside of school, such as in a
in our clinic reveal that just less than one half had restaurant or on the telephone, should also be explored.
mild to moderate expressive or receptive language delays A structured diagnostic interview, such as the Diag-
severe enough to warrant intervention (unpublished nostic Interview for Children and Adolescents-Parent
data). It appears that the rate of speech and language version (Herjanic and Campbell, 1977) or the Schedule
delays in the selectively mute population (and the for Affective Disorders and Schizophrenia for School-
impact of such delays) merits further investigation. Age Children-Epidemiologic Version (Orvaschel and
Puig-Antich, 1987) can be helpful for assessment of
comorbid psychiatric symptoms. Pervasive develop-
ASSESSMENT mental disorder, schizophrenia, and mental retardation
Any child who is being considered for a diagnosis can cause speech inhibition and thus might rule out
of selective mutism should have a comprehensive evalu- a diagnosis of selective mutism.
ation to rule out other explanations for the mutism and Academic ability should also be discussed. Because
to assess comorbid factors. An individualized treatment it is difficult to evaluate children with selective mutism
plan can then be developed. via traditional testing, minor learning disabilities may
be overlooked. Parent and teacher comments, academic
Parental Interview
reports, and standardized testing results can all be
Since most selectively mute children will not speak helpful to evaluate the child's skills and determine
to clinicians, an interview with the parent or guardian whether further testing is indicated.
of the child can provide essential information (Table 1). Reviewing the child's medical history is essential
A description of the child's symptom history, particu- because physical problems might underlie the child's
larly onset (sudden or insidious), may help establish mutism. Neurological injury or delay can result in
the diagnosis of selective mutism. Any patterns of speech and language problems or social skills deficits,
behavior that are not characteristic of selective mutism, both of which can exacerbate speech inhibition. In
such as not talking to immediate family members, addition, some authors have reported that early hospi-
abrupt cessation of speech in one environment, or talizations or abuse may playa role in the development
absence of speech in all settings, raise concerns about of selective mutism (MacGregor et al., 1994). Hearing
other neurological or psychiatric problems (e.g., autism, should also be checked (particularly if the child has a
aphasia). A history of neurological insult, develop- history of frequent ear infections), since hearing prob-
mental delays, neuropsychological deficits, and/or atyp- lems are sometimes associated with learning and lan-
ical speech and language difficulties (such as problems guage delays.
with prosody) could be suggestive of Asperger's disor- Family history of selective mutism, extreme shyness,
der, right hemisphere deficit disorder, or social erno- or anxiety disorders (social phobia, panic disorder,
tionallearning disabilities, rather than selective mutism obsessive-compulsive disorder) may put the child at
(Voeller, 1986; Weintraub and Mesulam, 1983). Chil- risk for developing similar problems and should be
dren with these disorders often have symptoms of thoroughly explored with the parents. In addition, a
shyness and social isolation and thus may appear similar complete family history of any psychiatric or medical
to selectively mute children, but research suggests that diagnoses, including response to treatment, can be
their symptoms are based on an inability to process helpful.
social cues. Evaluation of speech and language abiliry is essential.
Also of interest is the degree to which the child is Factors that might have influenced a child's language
verbally and nonverbally inhibited. Some selectively development, such as a parent with identified speech
mute children are shy and anxious in unfamiliar envi- and language problems, or a lack of adequate exposure
ronments, while others will interact in some way even to the language (as in some bilingual homes), should be
if they will not speak (perhaps by nodding their head considered. Inadequate or confusing language exposure
or smiling). Targeted questions about the child's verbal may result in expressive problems, and additional prac-
and nonverbal interaction, relationships with friends, tice may be necessary for the child to function at

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 34:7. JULY 1995 839

DOW ET AL.

TABLE 1
Assessment of Selectively Mute Children
Areas Parental Interview Clinical Interview

Symptoms • Type of onset (insidious, sudden) • Observations from interacting with

• Past treatments and efficacy the child
• Where and to whom the child will
speak
Social interaction • Ability to make and keep friends • Observations of temperament made
• Extent and pattern of participation in during interaction with child
social activities (shy? anxious? inhibited?
• Degree of shyness/inhibition in interactive?)
familiar and foreign settings
• Individuals to whom child will speak
• Ability to communicate needs
Psychiatric • Detailed assessment of psychiatric • Mental status examination
symptoms (use of a structured
interview is preferred by some)
• Family history of psychiatric
problems and excessive shyness
• Temperament during developmental
stages
Medical • Child's medical history, including • Physical examination, (including
illnesses or hospitalizations screening for neurological or
• Prenatal and perinatal histoty oral-sensorimotor problems)
• Developmental history
• Family medical history
Audiological • Frequency of otitis media • Peripheral sensitivity (pure-tone and
• Any reported concerns about hearing speech stimuli)
problems • Tympanometry and acoustic reflex
(for middle ear)
Academic and cognitive • Review of academic achievement • Standardized tests of cognitive skills
(grades, teacher reports) and achievement
Speech and language • Reported complexity and fluency • Receptive language: assess using
of child's speech at home standardized tests
• Nonverbal communication (gestures, • Expressive language: assess using
etc.) audiotape and standardized
• Any history of speech and language testing, if possible (note lengh of
delays utterances grammatical complexity,
• Detailed description of child's speech tone of voice)
production, language use • Speech: assess using audiotape (note
and comprehension fluency, pronunciation,
• Discussion of environmental rhythm, stress, inflection, pitch,
influences on language volume)
learning (bilingualism,
etc.)

normal levels. Other questions should focus on the explored. Other questions might focus on the child's
child's ability to communicate his or her needs, both speech production (voice, fluency, resonance, rate, and
verbally and nonverbally. Descriptions of the complex- rhythm), to identify phonological problems. It can also
ity and quality of language (mean length of utterance, be helpful to have parents provide an audiotape of the
range of vocabulary, use of difficult verb tenses and child speaking at home (as detailed later), because
complicated grammar) can help one evaluate expressive few children with selective mutism will actually speak
language ability. Pragmatic language abilities, such as to clinicians.
turn-taking in conversation, understanding of nonver- Many checklists have been used to assess speech and
bal communicative cues, and so on, should also be language ability, including the Classroom Cornmunica-

840 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:7, JULY 1995

 ASSESSMENT AND TREATMENT OF SELECTIVE MUTISM

tion Checklist (Ripich and Spinelli, 1985), the Interper- problems. In addition, tympanometry and acoustic
sonal Language Skills Checklist (McConnell and reflex testing can be used to assess middle ear function.
Blagden, 1986), and the Environmental Language In- Standardized psychological testing may be necessary
ventory (MacDonald, 1978). We adapted these scales to confirm parental and teacher reports of the child's
to create the National Institutes of Health Parent cognitive abilities, particularly because many of these
Checklist (Sonies et a!', 1993; available upon request), children are difficult to assess academically. While
which augments information provided by standardized learning disabilities are rarely the cause of mutism,
speech and language testing. In this questionnaire, they could exacerbate the problem. Tests of intellectual
parents are asked to respond to statements regarding capacity (which measure components of memory, atten-
the expressive, receptive, and pragmatic abilities of their tion, reasoning, and judgment) can be invaluable to-
child, indicating frequency (never, rarely, sometimes, ward obtaining a measure of the child's potential level
frequently, or always). This checklist, or others, can of functioning. Many different tests are available, but
be used to supplement standardized speech and lan- the performance section of the WISC-R (Wechsler,
guage testing. 1974) and Raven's Colored Progressive Matrices (Ra-
ven, 1976) were found to be good measures of cognitive
Child Assessment
ability in our selective mutism clinic since children
Interviewing the child is a crucial part of the assess- were not required to respond orally.
ment as it allows the clinician to directly observe the A formal speech and language evaluation, including
severity and nature of the child's mutism, as well as components of receptive language, expressive language,
to pursue any concerns raised by the parents (Table 1). and phonology, is an essential part of the assessment.
Temperament, quality of interaction, and ability While speech and language are closely tied, they are
to communicate verbally and nonverbally can all be separate entities and thus require different types of
observed during the interview with the child. As most assessment. Speech is cc • • • the activity of articulating
selectively mute children will not talk to the clinician, speech sounds," while language involves higher cortical
other forms of nonverbal communication (playing, functioning: " ... the communication of thoughts by
drawing) may be used to assess anxiety or shyness in the use of meaningful units combined in a systematic
social situations. Some selectively mute children will way" (Bishop, 1994, p. 556). A complete evaluation
avoid eye contact and withdraw from social situations, of the child's ability will utilize several different ap-
while others are more interactive and will smile, giggle, proaches, combining standardized testing with informa-
and nod answers to questions, even if they will not tion obtained from the parents, as well as an audiotape
speak. of the child speaking at home.
A review of the physical examination will ensure Most of the children referred to our selective mutism
that the child has no medical problems that could clinic had never received formal speech and language
potentially complicate the clinical picture. Oral sensory testing, perhaps in part because of a misconception
and motor ability should be evaluated, with particular that nonverbal children cannot be evaluated for speech
note to any orofacial abnormalities that might interfere and language functioning. Several tests of receptive
with articulation. Neurological difficulties, as evidenced language ability that can be administered to nonverbal
by drooling, grimacing, muscular asymmetry, tongue subjects are available. The Peabody Picture V ocabulary
and lip weakness, abnormal gag reflex, or impaired Test (Dunn and Dunn, 1981) is useful as an initial
sucking or swallowing, can be relevant because they may screening for receptive language problems, since it can
impede the movements necessary for normal speech. be administered nonverbally and it has been standard-
Auditory testing should be completed to ensure that ized for children as young as 2 years old. To evaluate
hearing difficulties are not contributing to the mutism. more complex receptive ability, one could use a variety
Several studies have shown that even mild audiological of other tests, including (but not limited to) the Token
impairments can have a negative effect on speech and Test for Children (DiSimoni, 1978), the Test for
language development (Fundudis et a!', 1979). General Auditory Comprehension of Language-Revised (Wool-
tests of peripheral sensitivity (using both pure-tone folk, 1985), the Test of Language Development (Ham-
and speech stimuli) are usually adequate to detect mil and Newcomer, 1982), and the Detroit Test of

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, .14:7, JULY 1995 841

DOW ET AL.

Learning Aptitude-Primary (Hammil and Bryant, using pharmacotherapy (using fluoxetine) (Black and
1986). For less responsive or immature children, the Uhde, 1994). Both studies reported success in the
Utah Test of Language Development (Mecham and treated group, as detailed in later sections.
Jones, 1989) or the Preschool Language Scale-3 (Zim-
merman et al., 1991) might be more appropriate. Behavioral
A prerecorded audiotape of the child speaking at Behavioral interventions, based on principles of
home can be used to evaluate phonological ability, learning theory, have been the most frequently used
including length of utterances, grammatical construc- treatment for selective mutism. Reed (1963) was one
tion, tone of voice, and response to verbalizations. In of the first to suggest that mutism could be a learned
addition, one should be alert for any abnormalities of behavior and thus might respond to behavioral tech-
rhythm, stress, inflection, pitch, or volume. Speech
niques such as reinforcement and stimulus fading. He
defects have been noted to cause speech inhibition in
hypothesized that mutism developed either as a means
some cases and thus could exacerbate the symptoms
of getting attention or as an escape from anxiety.
of selective mutism (Lerea and Ward, 1965).
Treatment was thus directed at extinguishing all rein-
TREATMENT forcement for the mutism, while simultaneously bol-
stering self-confidence and decreasing anxiety (Reed,
Treatment for selective mutism has for a long time
1963).
been considered difficult; some have described the
There have been many subsequent attempts to use
disorder as "intractable." Many different approaches
behavioral techniques to encourage speech in selectively
have been used to treat this disorder, including a variety
mute children (the reader is referred to Cunningham
of behavioral techniques, psychodynamic approaches,
et al., 1983; Labbe and Williamson, 1984; and Sanok
family therapy, speech therapy, and most recently phar-
and Ascione, 1979, for reviews). However, the only
macological intervention (for reviews, see Cline and
Baldwin, 1994; Kratochwill, 1981; Tancer, 1992). Un- controlled study of behavioral therapy to date was that
of Calhoun and Koenig (1973), which involved eight
fortunately, the majority of treatment reports have
selectively mute children. In this study, children were
been in case study format, many with only a single
subject. While case studies may be helpful to describe randomly assigned to treatment or control groups, and
a new approach or intervention, generalizing from such data (number of words per 30 minutes) were collected
reports can be problematic. In many of these reports, by trained observers at baseline, posttreatment, and
procedures were not sufficiently described to allow for follow-up. Although treatment was not described in
replication, outcome measures were not objective or sufficient detail to assess or replicate, it appeared to
standardized, alternative explanations for symptom re- consist of teacher and peer reinforcement of verbal
mission were not explored, and unsuccessful cases were behavior. Subjects who received active treatment were
not reported (Wells, 1987). found to have significantly more vocalizations than
Some authors have attempted to increase validity untreated subjects 5 weeks after the start of treatment
using a more systematic case study approach, the "sin- (p < .01), but improvement was not significant at
gle-case experimental design" (Bauermeister and Jemail, follow-up 1 year later (p < .10).
1975; Cunningham et al., 1983). For example, objec- In addition to this controlled study, there are numer-
tive symptom measures (such as number of words ous case reports of behavioral treatment for selective
spoken per hour) have been used to quantify outcome, mutism. Most authors used some type of reinforcement
and treatment results have been compared to baseline. for speaking, often combined with an absence of rein-
A few authors have even used multiple baselines (home, forcement for the mute behavior. Some also used
school, other settings). However, single-case experimen- punitive measures (forcing the child to sit in the corner,
tal design is still limited by small sample size, and splashing the child with water), but these may have a
systematic trials with larger groups are needed. Only tendency to increase a child's anxiety and thus would
two controlled studies of treatment for selective mutism not be recommended. Stimulus fading, a technique
were found in the literature, one using behavioral similar to the "desensitization" used to treat social
therapy (Calhoun and Koenig, 1973) and the other phobia, has also been reported to be an effective

842 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:7, JULY 1995

 ASSESSMENT AND TREATMENT OF SELECTIVE MUTISM

approach, particularly when combined with reinforce- has been done using family therapy as the primary
ment (the reader is referred to Heimberg and Barlow, intervention for selective mutism, reports suggest that
1991, for a review of cognitive-behavioral therapy for this approach can be effective in some cases (Goll,
social phobia in adults). In stimulus fading, therapists 1979).
set simple goals and then gradually increase the diffi- More recently, clinicians have not seen the child's
culty of the task. For example, Scott (1977) used this symptom as a result of family pathology, but rather
approach with a 7-year-old girl, gradually adding new they have tried to involve family members in the design
people into a room in which the girl was speaking. and implementation of a treatment plan. However, if
Three months after the end of treatment, Scott reported family problems are identified that may be having an
that, although she" ... will always be a shy child and impact on the child's symptoms, a more traditional,
will possibly experience difficulty in communication ... insight-oriented family treatment approach could be
the problem of mutism no longer exists" (Scott, 1977, appropriate.
pp. 269-270).
Other authors have reported on the effectiveness of Pharmacotherapy
techniques such as "shaping" to initiate speech in the
There are a few recent reports of pharmacological
school setting (Austad et al., 1980). Shaping is a
treatment for selective mutism, all using medications
procedure in which the therapist reinforces mouth
which have been helpful for social phobia (selective
movements that approximate speech until true speech
serotonin reuptake inhibitors). Golwyn and Weinstock
is achieved. "Self-modeling," a technique in which the
(1990) described a 7-year-old girl with elective mutism
child watches videotaped segments of himself or herself
and "associated shyness" who responded to phenelzine
performing desired behaviors (speaking, interacting),
(up to 2 mg/day) with improvement noted as early as
has also been tried with some success, though only
6 weeks. She progressed from not speaking a word at
with case studies (Dowrick and Hood, 1978; Pigott
school to being able to talk freely to teachers, peers,
and Gonzales, 1987).
and therapists. Her father had panic disorder and
Psychodynamic had responded to phenelzine. Black and Uhde (1992)
While insight-oriented psychodynamic therapy was described a 12-year-old girl with elective mutism and
at one time the preferred treatment for selective mutism, social anxiety who responded to fluoxetine (20 mg/
cognitive-behavioral approaches are now being used day): she was able to speak freely with adults and peers
with increasing frequency. Psychodynamic theory char- at school, and the response was maintained at 7 months.
acterizes mutism as a manifestation of intrapsychic Boon (1994) reported "positive effects" in the fluoxe-
conflict, and treatment is focused on identifying and tine treatment of a 6-year-old selectively mute girl but
resolving such underlying conflicts. The treatment pro- did not provide details.
cess can be time consuming, particularly if the child Black and Uhde (1994) recently completed a 12-
will not speak, and as a result many psychodynamic week trial of fluoxetine in children with elective mutism
therapists have utilized art or play to facilitate commu- (placebo-controlled, parallel design). The six children
nication and expedite therapy (Landgarten, 1975). taking active medication showed significant improve-
ment on some ratings of mutism and anxiety but not
Family Therapy on others, and subjects in both groups were still judged
In older reports, family pathology was often postu- to be symptomatic at the conclusion of the study.
lated to be a causal factor in the development of selective Although interesting and somewhat promising, these
mutism (Goll, 1979; Lindblad-Goldberg, 1986; Meijer, results suggest that perhaps a longer trial, a more
1979; Meyers, 1984; Pustrom and Speers, 1964). Au- individualized dosage schedule, or combined interven-
thors described patterns of interaction in the family tion should be considered. In obsessive-compulsive
which seemed to encourage the child's mutism and disorder, a combination of pharmacotherapy and be-
thus prevent resolution of the symptom (Meyers, 1984). havioral intervention is the treatment of choice (Leo-
Family therapy was used to identify and treat such nard et al., 1994). Several investigators are currently
dysfunctional patterns. Although no systematic research studying the efficacy of serotonin reuptake inhibitors

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:7, JULY 1995 843

DOW ET AL.

for the treatment of selective mutism, specifically fluox- the start of a behavioral program, expectations should
etine and fluvoxamine. A medication trial should be be kept low, perhaps rewarding the child for behaviors
considered if anxiety is a prominent factor or if symp- that he or she has already mastered or that are within
toms have been resistant to other treatment attempts. reach. Once the child has gained confidence in his or
her ability> the difficulty of the desired behavior can
Speech Therapy
be increased. For example, one might begin by re-
Several authors have noted an increased prevalence warding the child for whispering a single word and
of speech and language problems in the selectively gradually increase the expectations until the child is
mute population (Kolvin and Fundudis, 1981; Wilkins, saying the word in a normal volume. The type of
1985; Wright, 1968). Smayling (1959) was the first reward could also be chosen according to the child's
to use speech therapy as the primary intervention for preferences (favorite candy, social praise, etc.). Once
selective mutism, speculating that "speech defects, while the child has become comfortable speaking in one
not demonstrably the sole etiological factor, were caus- environment, attempts can be made to generalize speech
ally related to the mutism" (p. 58). In Smayling's to other individuals or environments, using techniques
report, six selectively mute children who had some such as stimulus fading.
degree of speech or language disability were treated The assistance of a speech therapist could be helpful
with half-hour sessions of speech therapy two to three in the development ofa behavioral program for selective
times per week until the problems were resolved (2 to mutism, even if no specific speech and language impair-
21 months). Therapists intentionally avoided men- ments have been identified. Some selectively mute
tioning the mutism or discussing the child's feelings, children have reported that they are afraid they will
instead focusing on articulation and language training. say the wrong thing or that their voice sounds funny,
Once the speech problems had been corrected, five of and speech and language practice could help such
the six children began to speak in school. Strait (1958) children gain confidence in their linguistic ability.
also used speech therapy, but in conjunction with Treatment might focus on perfecting pronunciation
behavioral modification techniques such as reinforce- skills, increasing comprehension, and learning prag-
ment. Though both Smayling and Strait studied chil- matic skills, such as turn-taking during conversation.
dren with identified speech and language problems, it Practicing real-life interchanges until they have become
is likely that any selectively mute child could benefit automatic and less stressful might eventually help re-
from structured language practice. duce a child's social inhibitedness.

School-Based Multidisciplinary Individualized SUMMARY

Treatment Plan
This article was developed in response to questions
An effective individualized treatment program could raised by families, clinicians, and educators in the
be implemented in the school environment, with the course of evaluating selectively mute children in our
coordinated efforts of parents, clinicians, and teachers. clinic. Although ongoing studies of phenomenology
The goal of a treatment program should be to decrease and treatment were not yet completed, it was thought
the anxiety associated with speaking while encouraging that there was an urgent need for practical information
the child to interact and communicate (Table 2). regarding assessment and treatment. Teachers and par-
Interventions that could be easily carried out by the ents had asked how to treat these children and had
classroom teacher include separating the class into small questioned the appropriateness of special educational
groups and identifying supportive peers. In some cases, placements, yet no literature was available to assist
an alternate means of communication (such as cards them and many of the clinicians they turned to were
or gestures) might initially be necessary to allow the unfamiliar with this disorder.
child to communicate basic needs. Any such system In our opinion, any child referred for selective mut-
should be kept simple, however, so the child will still ism deserves a comprehensive assessment that addresses
have incentive to communicate verbally. neurological, psychiatric, audiological, social, academic,
Behavioral approaches can be helpful for encouraging and speech and language concerns. In the past, many of
the child to interact both verbally and nonverbally. At these children have not received complete assessments,

844 J. AM. ACAD. CHILD [Link]. PSYCHIATRY, 34:7, JUl.Y 1995

 ASSESSMENT AND TREATMENT OF SELECTIVE MUTISM

TABLE 2
School-Based Multidisciplinary Intervention
Goals Specific Interventions

Decrease anxiety • Child should not be forced to speak

• Keep child in regular classroom unless special needs other than selective
mutism supersede
• Less emphasis on verbal performance (play nonverbal games)
• Encourage relationships with peers
• Cognitive-behavioral interventions: desensitization with relaxation
• Coordinate school-based program with out-of-school interventions (individual
and family psychotherapy, pharmacotherapy)
Increase nonverbal • Set up system for alternate means of communication (symbols, gestures, cards)
communciation • Small-group situations
• Facilitate peer relationships
Increase social interaction • Identify compatible peers for play in and out of school
• Small-group situations
• Activities that do not require verbal skills
• Activities that encourage social skills
Increase verbal communication • Structured behavioral modification plan: positive reinforcement for interactive
and communicative behaviors, eventually reinforcement for speech
• Speech and language therapy to develop linguistic skills
• Pragmatically based language practice

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