Selective Mutism Disorder

Key Features

Essentials of Diagnosis

• Consistent failure to speak in social settings (such as school) where this is expected, despite speaking in other settings

General Considerations

• More frequent in younger children

• Symptoms may be present before 5, but usually do not lead to problems until the child enters school

• Immigrant children or other children who initially learned one language and are expected to function in the school setting in a second language may present with selective mutism

Clinical Findings

Symptoms and Signs

• Can become angry and aggressive when facing a demand to speak

• Usually speak with close family members and may also speak with a "best" friend

• May be quite outgoing within this comfortable setting but are often shy outside of this setting

• Can be comfortable with social roles that do not require verbal communication

Differential Diagnosis

• Other disorders that can interfere with speech, such as autism, communication disorders, and psychotic disorders

• Comorbid anxiety disorders, such as social anxiety disorder, separation anxiety, and specific phobia

Diagnosis

• Screening for selective mutism is useful since families may not be aware of the problem, or may not appreciate that it is interfering with function at school

• To meet criteria for selective mutism, symptoms must interfere with function in school, work, or social communication, and must last longer than 1 month, not including the first month of school

• Symptoms cannot be due to autism, a communication disorder or psychotic disorders

Treatment

• Usually begins with psychoeducation

• Children can be difficult to engage due to their shyness, so clinicians must be adept at using both verbal and nonverbal methods to form an alliance with the child

• Cognitive-behavior therapy with exposure aimed at increasing verbal interactions can be very successful

• Patients with more severe symptoms, or symptoms that do not respond to therapy, may benefit from a selective serotonin reuptake inhibitor

Outcome

Prognosis

• Recognition and treatment is critical as the longer a child avoids verbal communication in settings outside of the family, the more entrenched this behavior becomes

• Children with untreated selective mutism are at risk for depression, and social anxiety disorder and substance abuse as adolescents

References