Selective mutism is a childhood disorder characterized by a child's inability to speak in certain social situations, such as school, despite being able to speak in other situations like at home. It typically emerges between ages 3-5 when children enter educational settings where speaking is expected. Children with selective mutism exhibit shyness, social anxiety, difficulty making eye contact or expressing emotions. Treatment focuses on behavioral techniques like stimulus fading and shaping to gradually increase verbalizations, as well as play therapy and relaxation training to reduce anxiety. Medication may also be used as an additional treatment method.

1. SELECTIVE MUTISM
Presented by:
Shaista Butt

2. Definition
Selective mutism, formally known as elective mutism,
is a disorder of childhood characterized by the persistent
lack of speech in at least one social situation (school),
despite the ability to speak in other situations (home).
Children with selective mutism will have difficulty
speaking, reading aloud, and singing aloud in front of
people outside of their family or their “comfort zone”.
(Silver, 1989).

3. Age of Onset
It is most prevalent between the ages of 3 and 5; onset
usually occurs when the child first enters an educational
framework in which speech is expected,
but sometimes onset is gradual – the child decreases
speech output until he eventually stops speaking (Silver,
1989).

4. Signs and Symptoms
Besides lack of speech, other behaviors displayed by selectively
mute people include:
• shyness,
• social anxiety, fear of social
embarrassment, and/or
social isolation and
withdrawal;
• use of gestures to get
message across;
• difficulty maintaining eye
contact, blank expression
and reluctance to smile;
(Silver, 1989).
• difficulty eating , or speaking
in front of audience;
• stiff and awkward movements;
• difficulty expressing feelings,
even to family members;
• tendency to worry more than
most people of the same age,
and sensitivity to noise and
crowds (Silver, 1989).

5. DSM V Criteria
• Consistent failure to speak in specific social situations
in which there is an expectation for speaking (e.g. in
classroom), despite speaking in other situations (e.g.
with mom in classroom).
• Disturbance interferes with educational/occupational
achievement or social communication.
• Disturbance must last for at least one month.
• Failure to speak is not due to lack of knowledge of or
comfort with the language in use.
• Disturbance is not better explained by communication
disorder (ex. Stuttering) (APA,2013)

6. Co morbidity
Selective mutism is co-morbid with a number of disorders
including:
– social anxiety disorder / social phobia,
– expressive language disorder,
– self-regulation – ability to adjust arousal and emotion in
appropriate manner,
– developmental speech delay,
– enuresis – bedwetting or daytime holding of urine for
prolonged intervals,
– separation anxiety disorder, depression,
– motor developmental disorders and oppositional defiance
disorder (Steinhausen, & Juzi, 1996).

7. Prevalence and Epidemiology
Most research has found that the incidence of SM is
around 0.07% that is seven children in every 1,000, and
it is 3 times that number in children from bilingual
homes.
Twice as many girls than boys have Selective Mutism
(Steinhausen, & Juzi, 1996).

8. Etiology and Pathogenesis
Selective mutism is caused by the interaction between
nature and nurture. One can conceptualize this as various
factors fitting into one of three groups, namely,
predisposing factors, precipitating factors, and
maintaining factors:
– Predisposing factors could include: anxiety of child, shyness,
timidity, and hyper-sensitivity; speech impairment of child
usually expressive language; bilingualism, negative self image
related to speech (e.g. doesn’t like sound of voice), neuro-
developmental delay, and often sensory processing disorder.

9. – Precipitating factors (triggers) could include: school or
kindergarten admission, frequent geographical moves, family
belonging to linguistic minority, negative reactions to child
talking – bullying, shouting etc.
– Maintaining factors could include: social isolation of
families, misdiagnosis, lack of early and appropriate
intervention. Lack of understanding by teachers, families,
psychologists; reinforcement of the mutism by increased
attention or affection; heightened anxiety levels caused by
pressure to speak; ability to convey messages non-verbally,
over acceptance of mutism (Silver, 1989).
Combination of predisposing factors and triggers can bring
about the onset of SM. (Blake &Moss, 1967).

10. Treatment
Often children with SM benefit from social skills
training and behavioral interventions. Medication can
sometimes be effective as an additional therapy.
• Behavioral treatment:
The speech-language pathologist may coordinate a
behavioral treatment program to increase verbalizations.
Behavioral treatment is based on the premise that the
child who is selectively mute is using the behavior in
response to anxiety in social situations. The focus of the
speech language pathologist’s intervention is to reinforce
communication with a gradual progression from non-
verbal to verbal (Steinhausen, & Juzi, 1996).

11. • Stimulus fading:
In stimulus fading, the speech-language pathologist sets
simple goals (e.g., using a gesture to communicate) and
gradually increases expectations until speech is achieved.
For example, child and parent may visit the child’s
classroom after school. The child is then encouraged to
talk to parent. A teacher may gradually be introduced at a
degree that she does not stop the verbalization of child.
The teacher enters the room; goes near parent and child,
parents introduce the teacher to child and relay
information between child and teacher. Once the teacher
is introduced the role of parent is gradually faded (Silver,
1989).

12. • Shaping:
Shaping involves rewarding approximations of target
speaking behavior.
For example, the child may be reinforced for mouth
movements accompanied by approximation of speech
(e.g., whispering) until true speech is achieved. Shaping
is often necessary in order to achieve positive outcome
for selectively mute child (Blake &Moss, 1967).

13. • Self-modeling:
Another technique sometimes used, when the child is
willing, is the self-modeling technique where the child
watches videotapes of himself or herself performing the
desired behavior (e.g., communicating effectively at
home) to facilitate self-confidence and carry-over of this
behavior into the classroom (Cunningham, McHolm, &
Melanie, 2005).

14. • Role playing:
The speech-language pathologist may also work with
specific speech and language problems that are
worsening the mute behavior.
For example, some children with SM are afraid to
speak because they feel they may say wrong thing. The
pathologist may use role-playing activities to lessen the
child's anxiety and increase confidence with speaking to
different listeners in a variety of settings. Other children
with SM may not want to speak because they feel their
voice “sounds funny”. The pathologist may work on
speech pronunciation to increase the clarity of speech
(Cunningham, McHolm, & Melanie, 2005).

15. • Reinforcement contingency:
It involves rewarding the child for speech behavior.
For example, allow and support parent and child to visit
school before school starts possibly multiple times.
Allow use of a verbal intermediary (parent, friend, doll,
puppet, and recording device) that makes the child more
comfortable in speaking/communicating. Reinforce
verbal AND non-verbal communication attempts
positively; be careful not to overdo the praise
(Cunningham & Melanie, 2005).

16. • Play therapy:
Play therapy aims to create an environment in which the
child feels free to express feelings, manage conflicts and
gives insight into and control over problems (Blake
&Moss, 1967).
• Relaxation training:
Individual exercises to help child release tension. (i.e.
“squeeze lemons” to feel tension and then relaxation in
hands/arms) are taught as well as group relaxation
exercises are also emphasized (Blake &Moss, 1967).

17. • Stages of Speech Emergence in School (least to most)
1. Complete mutism at school
2. Participates non-verbally
3. Speaks to parent at school (usually when teachers or students
are absent)
4. Peers see child speaking (but don’t hear)
5. Peers overhear child speaking
6. Speaks to Peer through Parent or Sibling
7. Speaks softly or whispers to one peer
8. Speaks to one peer w/normal volume
9. Speaks softly or whispers to several peers
10. Speaks in normal voice to several peers
11. Speaks softly or whispers to teacher
12. Speaks in normal voice to teacher
13. Normal Speech in School (Steinhausen, & Juzi, 1996).

18. References
American Psychiatric Association (2000). Diagnostic and
Statistical Manual of Mental Disorders (4th ed, text
revision). Washington, DC: American Psychiatric
Association.
Blake, P., & Moss, T. (1967). The development of socialization
skills in an electively mute child. Behavior Research and
Therapy, 5, 349-356.
Cunningham, E., McHolm, A., & Melanie, A. (2005). Helping
your child with selective mutism (3rd ed.). New York:
Harbinger Publications, Inc.