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Mutism, Selective

NORD is very grateful to Evdokia Anagnostou, MD, Clinician Scientist, Bloorview Research Institute, Assistant Professor, Department of Pediatrics, University of Toronto and Ellen Drumm, HBA, Clinical Research Associate, Holland Bloorview Kids Rehabilitation Hospital, for assistance in the preparation of this report.

Synonyms of Mutism, Selective

  • No synonyms found.

Disorder Subdivisions

  • No subdivisions found.

General Discussion

Selective mutism is a rare psychiatric condition primarily occurring during childhood. It is characterized by the failure to speak in certain social situations. The ability to speak and understand spoken language is not impaired, and may be exhibited in more familiar environments. Symptoms include excessive shyness and social anxiety.


Selective mutism is a rare psychiatric disorder characterized by persistent failure to speak
in specific social situations (e.g., school, with playmates, or when strangers are present) where speaking is expected. Affected individuals may communicate by gesturing, nodding their heads, uttering sounds or one-syllable words, or whispering. However, individuals with selective mutism usually talk normally at home and appear to have typical language skills - although they may have subtle language difficulties in areas such as grammar when compared to other children their age.

Symptoms may also include fear of social embarrassment, clinginess and anxiety. Individuals with selective mutism are also more likely to have anxiety disorders such as social phobia.

Individuals with selective mutism may be excessively shy, socially isolated, and withdrawn. In some cases, selective mutism lasts only a few weeks or months. However, some cases have been reported to continue for several years.

Symptoms of selective mutism usually become noticeable between the ages of two and four years. However, the diagnosis may not be apparent until the child has entered school or other social situations. Functioning in school and social situations may be impaired. Individuals with selective mutism are commonly compliant, reticent, and almost "frozen" around strangers.


The exact cause of selective mutism is unknown. Some research suggests a genetic
influence or "vulnerability" to selective mutism that interplays with environmental factors. Particular personal and family characteristics may contribute to the appearance of selective mutism. Individuals with selective mutism may come from families in which there is a history of anxiety disorders and/or shyness. The term "selective" means that these children fail to speak in some social settings. The cause is not due to an underlying physical abnormality.

Affected Populations

Selective mutism is recorded to affect less than one percent of children in the United States. This disorder appears slightly more common in females than in males. The percent of affected population is unknown due to undiagnosis and misdiagnosis.

Related Disorders

Symptoms of the following disorders can be similar to those of selective mutism.
Comparisons may be useful for a differential diagnosis:

Delayed speech and language development can be signs of a system abnormality, a
thinking/learning (cognitive) difficulty, or a hearing problem. This delayed development can also be a sign of emotional, social, family, or behavioral problems. The possibility of abnormalities of tracheal (windpipe) and laryngeal (voice box) function or oral-motor
development should be investigated by a physician.

Aphasia is a defect or loss of language function. Comprehension or expression of words
is impaired as a result of injury to the language centers in the brain. The most common form of aphasia occurs in people who have had a stroke or head injury. However, it can also occur in children as a congenital disorder. The severity of the brain injury determines the extent of impairment. Severe damage may cause the patient not to understand any information related to language. Smaller injuries may cause selective language impairment.

Pervasive developmental disorders comprise a group of neuro-psychiatric disorders
characterized by impairment in social skills, in the development of verbal and nonverbal
communication skills, and by the presence of repetitive behaviors/narrow restricted
interests. There may be delays in developing intellectual skills and language and speech,
as well as epilepsy. The severity and type of these impairments vary greatly from child to
child. The most well-known pervasive developmental disorder is autism.

Autism is a lifelong neurological disorder characterized by onset before 36 months of age, retarded development of communication and language, lack of normal response to people, and extreme sensitivity to changes in their environment. About two-thirds of autistic children have lower than normal IQs. Occasionally, a child shows distinct and unusual skills in music, mathematics, or using spatial concepts. Children with autism may have mild, moderate, or severe symptoms. Boys are affected four times more frequently than girls. (For more information on this disorder, choose "Autism" as your search term in the Rare Disease Database.)

Developmental expressive language disorder is an uncommon disorder characterized by
impairment in the development of expressive language. Language development is slow
with speech beginning late and progressing slowly. Severe forms usually occur before
age three. Less severe forms may not be evident until early adolescence.

Standard Therapies

The diagnosis of selective mutism may be confirmed by an extensive medical evaluation
to rule out other possible causes. The evaluation should include hearing tests to assure that the child is not hearing impaired. A child with selective mutism has the ability to
understand and speak spoken language but will not speak in some social situations. The Selective Mutism Questionnaire for parent or teacher may aid in diagnostic screening.

Treatment of selective mutism consists of behaviour management and psychotherapy (such as cognitive behavioural therapy and family therapy). A multi-modal approach is often recommended. The therapies that may be effective in treating selective mutism are counter-conditioning, modeling, shaping (successive approximations), and contingency management. Counter-conditioning involves developing new behaviors that are not compatible with the undesirable behaviors. Modeling includes demonstration of the appropriate behaviour and can also effectively include self-modeling. Self-modeling may involve repeatedly watching digitally edited video/audio recordings of the child exhibiting the desired behaviour, i.e. talking in social situations. Shaping is a method for developing complex behaviors by progressively reinforcing simple behaviors that will eventually lead to the desired complex behavior. Bribery and consequences should be avoided to meet this end. Contingency management consists of providing positive reinforcement to the child when something has been done correctly and consequences when an inappropriate behaviour has occurred.

Investigational Therapies

Use of the drug fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) is being studied for the treatment of selective mutism. More studies are needed to determine the long-term effectiveness of drugs for the treatment of selective mutism. Early evidence is promising and suggests that SSRIs are most effective when paired with behaviour management therapies.

Information on current clinical trials is posted on the Internet at
All studies receiving U.S. government funding, and some supported by private industry,
are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in
Bethesda, MD, contact the NIH Patient Recruitment Office:

Tollfree: (800) 411-1222
TTY: (866) 411-1010

For information about clinical trials sponsored by private sources, contact:

Contact for additional information about selective mutism:

Evdokia Anagnostou, MD
Child neurologist
Clinician Scientist, Bloorvew Research Institute
Assistant professor, Department of Pediatrics
University of Toronto
Phone: 416-753-6005
Fax: 416-753-6046

Mutism, Selective Resources



Black B, Leonard HL, Rapoport JL. Specific phobia, panic disorders, social phobia, &
selective mutism. In: Weiner JM. Ed. Textbook of Child and Adolescent Psychiatry, 2nd
Edition. Washington: American Psychiatric Press. 1997:491-506.

Nowakowski ME, Tasker SL, Cunningham CE, et al. Joint attention in parent-child dyads involving children with selective mutism: a comparison between anxious and typically developing children. Chil Psychiatry Hum Dev. 2011;42(1):78-92.

Vecchio J, Kearney CA. Treating youths with selective mutism with an alternating design of exposure-based practice and contingency management. Behav Ther. 2009;40(4):380-92.

Viana AG, Beidel DC, Rabian B. Selective mutism: A review and integration of the last 15 years. Clin Psyc Review. 2009;29:57-67.

Bergman RL, Keller ML, Piacentini J, et al. The development and psychometric properties of the Selective Mutism Questionnaire. J Clin Child Adolesc Psychology 2008; 37:456-64.

Manassis K, Tannock R. Comparing interventions for selective mutism: A pilot study. Can J Psychiatry. 2008;53(10):700-3.

Manassis K, Tannock R, Garland J, et al. The sounds of silence: Language, cognition, and anxiety in selective mutism. J Am Acad Child Adolesc Psychiatry. 2007;46(9):1187-95.

Cohan SL, Chavira DA, Stein MB. Practitioner review: Psychosocial interventions for children with selective mutism: A critical evaluation of the literature from 1990-2005. J Child Psych and Psychiatry. 2006;27:341-55.

Berger I, Jaworowski S, Gross-Tsur V. Selective mutism: a review of the concept and
treatment. Israel Med Assoc J: Imaj. 2002;4:1135-37.

Kumpulainen K. Phenomenology and treatment of selective mutism. CNS Drugs.

Kristensen H. Non-specific markers of neurodevelopmental disorder/delay in selective
mutism a case-control study. Eur Child Adolesc Psychiatry. 2002;11:71-78.

Bergman RL, Placentini J, McCracken JT. Prevalence and description of selective
mutism in a school based sample. J Am Acad Child Adolesc Psychiatry. 2002;41:938-46.

Kristensen H, Torgersen S. MCMI-II personality traits and symptom traits in parents of
children with selective mutism. J Ab Norm Psychology. 2001;110:648-52.

Gordon M. Mutism: elective or selective, and acquired. Brain Devel. 2001;23:83-87.
Stein MB, Chavira DA, Jang KL. Bringing up bashful baby. Developmental pathways to
social phobia. Psychiatric Clin North Am. 2001;24:661-75.

Stein MT, Rapin I, Yapko D. Selective mutism. J Devel Behav Pediatr. 2001;22(2

Kristensen H, Multiple informant's report of emotional and behavioral problems in
a nation-wide sample of selective mute children and controls. Eur Child Adolesc
Psychiatry. 2001;10:135-42.

Remschmidt H, Poller M, Herpetz-Dahlmann B, et al. A follow up study of 45 patients
with elective mutism. Eur Arch Psychiatry Clin Neurosci. 2001;251:284-96.

Anstendig KD. Is selective mutism an anxiety disorder? Rethinking the DSM-IV
classification. J Am Acad Child Adolesc Psychiatry. 2000;39:249-56.

Kristensen H. Selective mutism and comorbidity with developmental disorder/delay,
anxiety disorder, and elimination disorder. J Am Acad Child Adolesc Psychiatry.

Connolly SD, Suarez L, Sylvester C. Assessment and treatment of anxiety disorders in children and adolescents [published online ahead of print January 12, 2011]. Curr Psychiatry Rep. 2011. Accessed March 10, 2011.

The information in NORD’s Rare Disease Database is for educational purposes only. It should never be used for diagnostic or treatment purposes. If you have questions regarding a medical condition, always seek the advice of your physician or other qualified health professional. NORD’s reports provide a brief overview of rare diseases. For more specific information, we encourage you to contact your personal physician or the agencies listed as “Resources” on this report.

Report last updated: 2011/03/10 00:00:00 GMT+0

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