• Disease Overview
  • Signs & Symptoms
  • Causes
  • Affected Populations
  • Disorders with Similar Symptoms
  • Diagnosis
  • Standard Therapies
  • Clinical Trials and Studies
  • References
  • Programs & Resources
  • Complete Report

Mutism, Selective


Last updated: March 10, 2011
Years published: 1989, 1997, 2003, 2004, 2011


NORD gratefully acknowledges 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.

Disease Overview

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.

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Signs & Symptoms

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Individuals with selective mutism may be excessively shy, socially isolated, and withdrawn.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.

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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.

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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.

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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 assur. 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.

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Standard Therapies


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.

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Clinical Trials and Studies

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 www.clinicaltrials.gov.

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

Email: [email protected]

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

Email: [email protected]

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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.

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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.

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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.

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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.

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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. http://www.ncbi.nlm.nih.gov/pubmed/21225481. Accessed March 10, 2011.

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Programs & Resources

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Patient Organizations

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