The document discusses the history and diagnosis of selective mutism. It notes that selective mutism was previously called elective mutism and was added to the DSM-III in 1980. At that time, it was poorly understood and theories blamed parents or trauma as causes. The establishment of the Selective Mutism Foundation in 1991 led to renaming it selective mutism in DSM-IV in 1994 and eliminating unfounded theories by providing research. Placement in the DSM and whether it is an anxiety disorder or communication disorder has been controversial. The document outlines the current diagnostic criteria and classification in DSM-IV-TR.

1. In 1980, when the DSM III (third edition) was published, it included “Elective Mutism” (now renamed
Selective Mutism)
Selective Mutism, (previously Elective Mutism) until the inception of our organization in 1991, was virtually
ignored, and regardedas a rare and low public interest disorder. As such, input for the DSM III and DSM
III-R had to be drawn from available literature. There were no comprehensive research studies prior to the
development of the Selective Mutism Foundation, Inc., only a few
compromised studies and single case studies, based upon theories. The available literature presented
conflicting theories, withmost describing Elective Mutism’s essential feature as a “refusal” to speak along
with characteristics of willful, controlling, and
manipulative behaviors, caused by maternal over protection, abuse, trauma, or family dysfunction. Even
the name, ElectiveMutism, was indicative of a deliberate refusal to speak to EVERYONE and in ALL
environments. There was no distinction
between sudden mutism possibly caused by a traumatic event, and shyness or social anxiety. There was
also no distinctionbetween a speech or language communication disorder and social phobia. All of these
characteristics, and more, were summed together within the diagnostic and associated features of
Elective Mutism in the DSM III and III-R. The Selective MutismFoundation’s input, in 1991, was the major
source in eliminating theories and replacing them with sound facts, including renaming
the disorder to Selective Mutism, for the DSM IV, 1994.
There were, indeed, some professionals who were intuitive and recognized social anxiety, however, for
the most part, many
parents were blamed for their child’s silence. Parents were blamed, and felt guilty, for something that
they themselves did not
understand. Many parents reported previously having mutism themselves, however they were confused
by the theories. They
were not yet equipped with evidence, or specifically, credible published research studies to defend their
children or themselves.
The Selective Mutism Foundation’s efforts, through research encouragement and participation, since
1991, have been and
continue to be the only major source acknowledged nationally to positively effect Selective Mutism criteria
for the DSM.
It is important to clarify 2 crucial issues of confusion that are not visible in the DSM. The 2 areas of
ongoing confusion pertain to
why Selective Mutism was not classified as an Anxiety Disorder, or under “Communication Disorders”,
within “Disorders Usually
First Diagnosed In Infancy, Childhood, or Adolescence”. The DSM Children’s Anxiety Disorders section
was discontinued prior to
recognition of Elective Mutism in the DSM, in an effort to prevent misdiagnosis. As children may not
recognize or be able to
express their fears or symptoms, assumptions or uncertainty was thereby eliminated. The DSM does
have an Anxiety Disorders
section for diagnosing adults, with inferences to those under 18 years of age. In addition, the listed
conditions under “Anxiety
Disorders” (e.g. social phobia, specific phobia) obviously cannot imply the essential feature to be a failure
to speak in specific

2. situations. Within the Associated Features and Disorders for Selective Mutism, it is however indicted, that
the additional
diagnosis of Anxiety Disorder, especially Social Phobia is usually given (DSM-IV TR)
The placement of Selective Mutism under “Communication Disorders” was prior to the inception of our
organization, a controversial
issue. Current published studies, some that include research participants from our organization confirm
that Selective Mutism is
not a language impairment. Published studies and statistics also reveal that Speech/Language
therapy including within school
systems is inappropriate for the Selective Mutism population. It has been established, for over a decade,
that children
experiencing Selective Mutism have the ability to comprehend and to speak normally in comfortable
settings.
The DSM IV and DSM IV-TR, as you can see, under Selective Mutism's Diagnostic Features and
Differential Diagnosis, clearly
indicate that Selective Mutism should be distinguished from speech impairments, and that Selective
Mutism should be diagnosed
if the child’s failure to speak is not considered a language impairment. It is further clarified that
communication disorders are not
restricted to certain settings in contrast to Selective Mutism.
The DSM IV and DSM IV-TR reflect that language impairments, an Associated Disorder, may
occasionally coexist with Selective
Mutism, although not an essential feature and confirms, in Diagnostic Criterion E that Selective Mutism is
not better accounted for
by a Communication Disorder. As a result, Selective Mutism remains classified in “Disorders Usually First
Diagnosed in Infancy,
Childhood, or Adolescence”, under “Other Disorders”, rather than under "Communication Disorders".
DSM IV-TR 2000
Diagnostic and Statistical Manual of Mental Disorders
USUALLY FIRST DIAGNOSED IN INFANCY, CHILDHOOD, OR ADOLESCENCE
313.23 Selective Mutism
(formerly Elective Mutism)
Diagnostic Features
The essential feature of Selective Mutism is the persistent failure to speak in specific social situations
(e.g., school, with
playmates) where speaking is expected, despite speaking in other situations (Criterion A). The
disturbance interferes with
educational or occupational achievement or with social communication (Criterion B). The disturbance
must last for at least 1
month and is not limited to the first month of school (during which many children may be shy and reluctant
to speak) (Criterion
C). Selective Mutism should not be diagnosed if the individual’s failure to speak is due solely to a lack of
knowledge of, or comfort
with, the spoken language required in the social situation (Criterion D). It is also not diagnosed if the
disturbance is better
accounted for by embarrassment related to having a Communication Disorder (e.g., Stuttering) or if it
occurs exclusively during a

3. Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder (Criterion E). Instead of
communicating by
standard verbalization, children with this disorder may communicate by gestures, nodding or shaking the
head, or pulling or
pushing, or, in some cases, by monosyllabic, short, or monotone utterances, or in an altered voice.
Associated Features and Disorders
Associated features of Selective Mutism may include excessive shyness, fear of social embarrassment,
social isolation and
withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling or oppositional
behavior, particularly at home.
There may be severe impairment in social and school functioning. Teasing or scapegoating by peers is
common. Although
children with this disorder generally have normal language skills, there may occasionally be an
associated Communication
Disorder (e.g., Phonological Disorder, Expressive Language Disorder, or Mixed Receptive-Expressive
Language Disorder) or a
general medical condition that causes abnormalities of articulation. Mental Retardation, hospitalization,
or extreme psychosocial
stressors may be associated with the disorder. In addition, in clinical settings, children with Selective
Mutism are almost always
given an additional diagnosis of an Anxiety Disorder (especially Social Phobia).
Specific Culture and Gender Features
Immigrant children who are unfamiliar with or uncomfortable in the official language of their new host
country may refuse to speak
to strangers in their new environment. This behavior should not be diagnosed as Selective Mutism.
Selective Mutism is slightly
more common in females than in males.
Prevalence
Selective Mutism is apparently rare and is found in fewer than 1% of individuals seen in mental health
settings.
Course
Onset of Selective Mutism is usually before age 5 years, but the disturbance may not come to clinical
attention until entry into
school. The degree of persistence of the disorder is variable. It may persist for only a few months or may
continue for several
years. In some cases, particularly in those with severe Social Phobia, anxiety symptoms may become
chronic.
Differential Diagnosis
Selective Mutism should be distinguished from speech disturbances that are better accounted for by a
Communication
Disorder, such as Phonological Disorder, Expressive Language Disorder, Mixed Receptive-
Expressive Language
Disorder, or Stuttering. Unlike Selective Mutism, the speech disturbance in these conditions is not
restricted to a specific social
situation. Children in families who have immigrated to a country where a different language is spoken
may refuse to speak the
new language because of lack of knowledge of the language. If comprehension of the new language is
adequate, but refusal
to speak persists, a diagnosis of Selective Mutism may be warranted. Individuals with a Pervasive
Developmental Disorder,

4. Schizophrenia or other Psychotic Disorder, or severe Mental Retardation may have problems in
social communication and
be unable to speak appropriately in social situations. In contrast, Selective Mutism should only be
diagnosed in a child who has
an established capacity to speak in some social situations (e.g., typically at home). The social anxiety
and social avoidance in
Social Phobia may be associated with Selective Mutism. In such cases, both diagnoses may be given.
Diagnostic criteria for 313.23 Selective Mutism
A. Consistent failure to speak in specific social
situations
(in which there is an expectation for
speaking, e.g., at
school) despite speaking in other situations.
B. The disturbance interferes with educational
or
occupational achievement or with social
communication.
C. The duration of the disturbance is at least 1
month (not
limited to the first month of school).
D. The failure to speak is not due to a lack of
knowledge
of, or comfort with, the spoken language
required in the
social situation.
E. The disturbance is not better accounted for
by a
Communication Disorder (e.g., Stuttering)
and does
not occur exclusively during the course of a
Pervasive
Development Disorder, Schizophrenia, or
other
Psychotic Disorder.
iagnosis of other comorbid anxiety disorders are also commonly diagnosed with SM and social
phobia (Biedel & Turner, 1998). The name change from "elective" to "selective mutism" in
DSM-IV deemphasized the oppositional behavior connotation that a child elected not to speak
and rather emphasized the characteristic of the disorder, that there are select environments in
which speaking does not occur (APA, 1994). The term selective mutism is consistent with new
etiological theories that focus on anxiety issues (Dow et al., 1995).
The current edition, DSM-IV-TR (APA, 2000) states that the following criteria must be met in
order to qualify for a diagnosis of selective mutism:

5. An inability to speak in at least one specific social situation where speaking is expected (e.g., at
school) despite speaking in other situations (e.g., at home); The disturbance has interfered with
educational or occupational achievement or with social communication; The duration of the
selective mutism is at least one month and is not limited to the first month of school; The
inability to speak is not due to to a lack of knowledge of or discomfort with the primary language
required in the social situation; and, The disturbance cannot better be accounted for by a
communication disorder (e.g. stuttering) and does not occur exclusively during the course of a
pervasive developmental disorder, schizophrenia or other psychotic disorder.
Consistent with current research, SMG believes that Selective Mutism is best understood as a
childhood social communication anxiety disorder. SM is much more than shyness and most
likely on the spectrum of social phobia and related anxiety disorders. SM is NOT a child
willfully refusing to speak.
Most children with selective mutism are believed to have an inherited predisposition to anxiety.
They often have inhibited temperaments, which is hypothesized to be the result of over-
excitability of the area of the brain called the amygdala.[5] This area receives indications of
possible threats and sets off the fight-or-flight response.
Some children with selective mutism may have sensory integration dysfunction (trouble
processing some sensory information). This would cause anxiety and a sense of being
overwhelmed in unfamiliar situations, which may cause the child to "shut down" and not be able
to speak (something that some autistic people also experience). Many children with SM have
some auditory processing difficulties.
About 20–30% of children with SM have speech or language disorders that add stress to
situations in which the child is expected to speak.[6]
Despite the change of name from "elective" to "selective", a common misconception remains
that a selectively mute child is defiant or stubborn. In fact, children with SM have a lower rate of
oppositional behavior than their peers in a school setting.[7] Another common belief is that
selectively mute children have experienced abuse or trauma. A study of six adults who were
selectively mute as children suggests that those with selective mutism are more likely to have
suffered abuse, which may contribute to the onset of their mutism. The interviewees also said
that there was a conscious determination not to speak and that they were afraid of speaking,
indicating that both choice and fear may be involved in selective mutism. Only two of the
interviewees specifically reported childhood social anxiety, and those were twins. Other anxiety
and emotional problems seemed to have appeared after the onset of the disorder. This study
shows that selective mutism may be more complex than currently believed, with both past and
current understandings of the disorder both being partly true.[8]
In their book Adoption Detective: Memoir of an Adopted Child, Judith and Martin Land mention
how selective mutism, extreme shyness, and other social anxiety disorders can be evidence of
trauma frequently associated with adoption, especially in children under three years old.
Selective mutism might be highly functional for a child by reducing anxiety and protecting the
child from perceived challenges of social interaction, particularly in situations with high

6. performance expectations, such as school. Adoptees with this anxiety might be highly talkative
at home with family and friends, but avoid speaking altogether in classrooms, large groups, and
social functions. Adoptees with selective mutism likely have difficulty verbalizing personal
thoughts when they are excessively revealing and painful or of a subconscious nature.
The Diagnostic and Statistical Manual of Mental Disorders (DSM), first published in 1952, first
included Elective Mutism in its third edition, published in 1980. Elective Mutism was described
as "a continuous refusal to speak in almost all social situations" despite normal ability to speak.
While "excessive shyness" and other anxiety-related traits were listed as associated features,
predisposing factors included "maternal overprotection", mental retardation, and trauma.
Elec2tive Mutism in the third edition revised (DSM III-R) is described similarly to the third
edition except for specifying that the disorder is not related to Social Phobia.
In 1994, Sue Newman, co-founder of the Selective Mutism Foundation, requested that the fourth
edition of the DSM reflect the name change to selective mutism and described the disorder as a
failure to speak. The relation to anxiety disorders was emphasized, particularly in the revised
version (DSM IV-TR).
There are no changes to the definition of selective mutism planned for the DSM V.
Treatment
Contrary to popular belief, people suffering from selective mutism do not necessarily improve
with age.[11] Effective treatment is necessary for a child to develop properly. Without treatment,
selective mutism can contribute to chronic depression, further anxiety, and other social and
emotional problems.[12][13]
Consequently, treatment at an early age is important. If not addressed, selective mutism tends to
be self-reinforcing. Those around such a person may eventually expect him or her not to speak
and therefore stop attempting to initiate verbal contact with the sufferer. Alternately, they may
pressure the child to talk, making him or her have even higher anxiety levels in situations where
speech is expected. Because of these problems, a change of environment (such as changing
schools) may make a difference, and treatment in teenage or adult years can be more difficult
because the sufferer has become accustomed to being mute.
The exact treatment depends on the sufferer's age, other mental illnesses he or she may have, and
a number of other factors. For instance, stimulus fading is typically used with younger children,
because older children and teenagers recognize the situation as an attempt to make them speak,
and older sufferers and people with depression are more likely to need medication.[14]
[edit] Self-Modeling
The child is brought into the classroom or the environment where s/he will not speak and is
videotaped answering a series of questions. First, his/her teacher, or adult representative of those
to which the child will not speak asks the child questions. The child likely does not answer the
questions at this time. A parent or someone to whom the child will converse verbally then comes

7. in the room and the teacher goes out. The comfortable adult asks the child the same questions,
this time eliciting a verbal response. This video is then edited so that the it looks like the child is
answering the questions posed by the teacher. This video is then shown the child over a series of
several weeks. The child is asked to view the tape and every time s/he sees him/herself
answering the teacher verbally, stop the tape to receive a positive reinforcement.
The video can also be shown to the child’s classroom in order to set an expectation in the
classroom by his/her peers that s/he speaks. The classmates now know the sound of the child’s
voice and believe they have seen the child conversing with the teacher.[15][16]
[edit] Mystery Motivators
Mystery motivation is often seen paired with the self-modeling technique. An envelope is placed
in the child’s classroom in a visible place. On the envelope, the child’s name is written along
with a question mark. Inside is a prize determined with the child’s parent in order for it to be
something the child would want to have. The child is told that when s/he asks for the envelope
appropriately and loudly enough for the teacher and his/her peers to hear, s/he may then receive
the mystery motivator. The classroom is also told in this case about the expectation that the child
ask for the envelope loudly enough that the class can hear.[17][18][19]
[edit] Stimulus fading
The subject is brought into a controlled environment with someone with whom they are at ease
and can communicate. Gradually, another person is introduced into the situation. One example of
stimulus fading is the sliding-in technique, where a new person is slowly brought into the talking
group. This can take a long time for the first one or two faded-in people but may become faster
as the patient gets more comfortable with the technique.
An example of this would be a child playing a board game with a family member in his/her
classroom at school. Gradually, the teacher is brought in to play as well. When the child adjusts
to his/her presence, then a peer is brought in to be a part of the game. Each person is only
brought in if the child continues to engage verbally and positively.[20][21][22]
[edit] Desensitization
The subject communicates indirectly with a person he or she is afraid to speak to through such
means as email, instant messaging (text, audio, and/or video), online chat, voice or video
recordings, and speaking or whispering to an intermediary in the presence of the target person.
This can make the subject more comfortable with the idea of communicating with this person.
[edit] Shaping
The subject is slowly encouraged to speak. He or she is reinforced first for interacting
nonverbally, then for saying certain sounds (such as the sound that each letter of the alphabet
makes) rather than words, then for whispering, and finally saying a word or more.[23]

8. Spacing
Spacing is important to integrate, especially with self-modeling. Repeated and spaced out use of
interventions is shown to be the most helpful long-term for learning. Viewing videotapes of self-
modeling should be shown over a spaced out period of time of approximately 6 weeks.[24][25][26]
Drug treatments
Many practitioners believe that there is evidence indicating that antidepressants such as SSRIs
may be helpful in treating children and adults with selective mutism and even that medicine is
essential to effective treatment.[citation needed]The medication is used to decrease anxiety levels to
speed the process of therapy. Use of medication may end after nine to twelve months, once the
person has learned skills to cope with anxiety and has become more comfortable in social
situations.[27] Medication is more often used for older children, teenagers, and adults whose
anxiety has led to depression and other problems.
Medication, when used, should never be considered the entire treatment for a person with
selective mutism. While on medication, the person should be in therapy to help him or her to
know how to handle anxiety and prepare him or her for life without medication.[28]
Anti-depressants have been used in addition to self-modeling and mystery motivation in order to
aid in the learning process.[29][30]
Do Individuals Experiencing Selective Mutism Have Associated Behaviors?
Yes. Associated behaviors may include no eye contact, no facial expression, immobility, or nervous
fidgeting when confronted with
general expectations in social situations. These symptoms do not indicate willfulness, but rather an
attempt to control rising
anxiety.
Some may withdraw by pulling back when approached or touched and exhibit different forms of body
language. In many cases the
body language has been misinterpreted as abuse, however, we have found that these behaviors stem
from anxiety. Based on
responses to the Foundation, we suspect that some may have Obsessive-Compulsive Disorder (OCD) or
Tourette Syndrome type
symptoms, and a variety of phobias as well.