Selective Mutism in Children:
A Psychogenic Voice Disorder
Emily Buchanan
April 1, 2003
Definition in the Diagnostic and
Statistical Manual of Mental Disorders
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The persistent refusal to talk in one or more social situations, including
school
Consistent failure to speak in specific social situations in which there
is an expectation for speaking (e.g., school), despite speaking in other
situations
The disturbance interferes with educational or occupational
achievement or with social communications
The duration of the disturbance is at least 1 month (not limited to the
first month of school)
Failure to speak is not limited to lack of knowledge or comfort with
social language required (e.g., bilingual or immigrant children)
(American Psychiatric Association, 1994)
Symptoms:
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Excessive shyness
Fear of social embarrassment
Social isolation
Withdrawal
Impulsive traits
Negativism
Clinging behavior
Temper tantrums
Controlling or oppositional behaviors
Theories of causation
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Immigrant family background
Significant early childhood trauma
Injury that affects the mouth
Possible family secrets
Anxiety is most commonly an underlying
feature!
Problems of Selective Mutism
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Provides limited opportunity for social
interaction and growth
Delays the development of appropriate oral
reading and work attack skills
Hinders the involvement in normal school
activities
Prevalence
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Estimated to occur in less than .8 per 1,000 of
the population
Slightly more common in females than males
Onset is usually before 5 years
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Many times disturbances may not come into
attention until entry into school
One or both parents of a selectively mute child
have a history of anxiety symptoms, including
shyness, social anxiety, or panic attacks
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Suggests the child’s anxiety is a familial trend!
(Giddan et. Al, 1997)
History
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Previously called elective mutism, renamed in
1987
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Covers broad spectrum from psychoanalytic schools of
Europe in 1800s to contemporary behavioral interventions
In early German literature, selectively mute children were
removed from the home and place in residential treatment
centers
A Norway study by Wergeland (1979) described
selectively mute children who were removed from their
homes from 8 months to 3 years
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Found that untreated children were better at follow-up than the
children who had been removed from their homes
(Giddan et. Al, 1997)
History con’t
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Little attention paid to associated speech and
language problems in children with selective
mutism until Baltaxe (1994) who examined 12
years of records at the UCLA Neuropsychiatric
Institute:
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Of the 24 patients identified:
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75% had articulation problems
86% failed auditory processing measures
60% demonstrated receptive language problems
75% showed expressive deficits
(Baltaxe, 1994)
Psychoanalytic View
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Psychoanalysts: children who are orally fixated
wish to punish their parents
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They may be maintaining a family secret, displacing
hostility toward the mother, or regressing to a preverbal stage
Atoynatan (1986) believed the mutism was a
vehicle for the mother’s unexpressed hostility
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Through it, the child achieves an exclusive
relationship with the mother
(Atoynatan, 1986)
Behavioral View
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Selective mutism is the product of a long
series of negatively reinforced learning
patterns
Approaches reduce anxiety about talking
and/or reinforcing the child for speaking
(Giddan et. Al, 1997)
SLP roles in Selective Mutism
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Communication and Linguistic specialist
 Often the first consulted when a child is not talking
in school
Coordinate efforts of a multidisciplinary team
 Psychologist, psychotherapist, social worker,
classroom teacher, special education teacher, parents,
peers
Important contributors to the programs designed for the
child
Education for other professionals, teachers, parents/family
Help the teacher develop different methods of assessment
of the child’s reading abilities
Advocate/Confidant for the child
Diagnosing
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SLPs first must refer the parents and child to a
mental health practioner!
Assess the child’s receptive language
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To make linguistic diagnoses, the SLP will have to
rely on language samples recorded on audio- or
videotape at home
Then, remediation of the linguistic aspect of the
problem can only be addressed once speech has
been initiated in the therapy setting
Treatment Types
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Two pronged approach:
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Individual psychotherapy to help reduce the general
anxiety
A behavioral program at school to slowly shape
appropriate communication
Treatment revolves around:
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contingency management: rewards speaking behavior
and ignores non-speaking behavior
stimulus fading: introduces a new person to a
situation where the child normally speaks
response initiation: encouraging child to initiate
communication
(Schum, 2002)
Treatment Types
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(Krohn, Weckstein, & Wright, 1992) developed a
response initiation approach
Begins with a psychiatric evaluation, information
presented to parents, and a brief period of therapy
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Children given message that speaking is necessary
Therapist schedules a complete day when child
will spend the day with the therapist
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The child is required to speak one word to the
therapist before leaving the therapist’s office
Most children speak within 1-2 hours, rarely more than 4
hours needed
 Goals are then set!
(Krohn, et. Al, 1992)
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Psychoeducational Approach
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Multidisciplinary approach, includes psychologist,
SLP, classroom teacher, parents
Psychotherapy and Speech and Language Therapy
Encourage nonverbal gestures:
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Making eye contact, following directions, nonverbal
participation in group activities, pantomime activities,
Leads to Stimulus Fading
Response Initiation, whispering
Expand on verbalizations by having child choose
what things to say
Psychoeducational Approach
con’t
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Child must agree to whisper in SLP sessions
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Shaping, encourage use of other vocalizations
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Generalize to classroom teacher, an aide, others in
the school environment, peers
Cough, sounds with a kazoo, animal sounds
Increase volume, child must be interested and
animated about topics
Generalize voice to specific words, class subjects,
and finally different settings
Must use reinforcing Rewards!
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(Giddan et. Al, 1997)
Peer Approach
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Involve the child with peers in various activities
Most selectively mute children are well accepted and
liked
SLP identifies which peers show a mutual interest in the
child
Collaborates with teacher to set up instructional situations
in which the child is paired with a preferred peer
Peer can also attend speech and language therapy sessions
Generalize from short activities to therapy sessions to
home visits to activities outside home and school
(Schum, 2002)
Videotape/Audiotape Approach
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Self Modeling
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Child can see what it will be like when the child talks
Tape at home, listened to at therapy
Good for children who are resistant to behavioral
therapy
Video freeforward:
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Videotapes of the child talking obtained in situations
in which the child talks fluently are edited with
videotapes of the child in situations in which the
child does not talk so that the edited intervention
videotape depicts that child talking in situations in
which he or she has been mute.
(Blum, N.J. et. Al, 1998)
Treatment Issues
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The longer the child is silent, the more entrenched
the behavior gets
Course of treatment is unpredictable
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Based on length of time the behavior has existed,
personality factors, willingness of the significant
others to focus on the problem
Selectively mute children often found in
immigrant populations
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Due to cultural and linguistic differences between
home and school
Treatment Issues con’t
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Recent medical literature reports use of
antidepressants to treat selective mutism
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Routine and structure important for an anxious
child, know what is to come
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Helpful in treating anxiety symptoms, does not treat
mute behaviors
Often “slow to warm up”, let the child observe first
(Schum, 2002) suggests using terms such as “shy”
and “nervous” to describe feelings when they are
reluctant to speak, and “brave” when they speak
(Schum, 2002)
Treatment Issues con’t
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Selectively mute children are often
inadvertently rewarded for not talking
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Follow rules, quiet
Fellow classmates often reinforce, support,
and enable silence by speaking for the child
Easy for people to become frustrated with
the child
Works Cited
1Up Health. Selective Mutism. Retrieved March, 30, 2003, from
http://www.1uphealth.com/health/selective_mutism_info.html
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
Atoynatan, T.H. (1086). Elective Mutism: Involvement of the mother in the treatment of the
child. Child Psychiatry and Human Development, 17, 15-27.
Baltaxe, C.A.M. (1994, November). Communication issues in selective mutism. Paper
presented at the American Speech-Language-Hearing Association Convention, New
Orleans, LA.
Blum, N.J. (1998, February). Case study: audio freeforward treatment of selective mutism.
Journal of the American Academy of Child and Adolescent Psychiatry, 37, 40-43.
Giddan, J.J., Ross, G.J., Sechler, L.L., Becker, B.R. (1997). Selective mutism in elementary
school: multidisciplinary interventions. Language, Speech and Hearing Services in
Schools, 28, 127-133.
Krohn, D.D., Weckstein, S.M., & Wright, H.L. (1992). A study of the effectiveness of a
specific treatment for elective mutism. Journal of the American Academy of Child and
Adolescent Psychiatry, 31, 711-718.
Schum, R. (2002). Selective mutism: an integrated treatment approach. ASHA Leader
online.
Wergeland, H. (1979). Elective mutism: Acta Psychiatrica Scandinavica, 59, 218-228.