Applied Evidence

When a child won’t speak

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They may be “chatterboxes” at home, but kids with selective mutism don’t speak at all at school. Eight questions can help you assess, and address, this disorder.



Strength of recommendation (SOR)
  1. Good-quality patient-oriented evidence
  2. Inconsistent or limited-quality patient-oriented evidence
  3. Consensus, usual practice, opinion, disease-oriented evidence, case series
Practice recommendations
  • Assess children with selective mutism for severe social anxiety (C).
  • Drug therapy for anxiety and depressive conditions related to selective mutism and collaboration with school personnel and parents can help a child increase her frequency and audibility of speech in public settings (C).
  • Exposure-based practices can help children with selective mutism to speak in public places (C).

Lucy’s parents were having difficulty reconciling the child they knew at home with the one they sent to school. At home, the 7-year-old spoke easily with her parents and siblings. At school and in other public places such as the supermarket, mall, or park, she would not speak at all. This had been going on for several years.

While Lucy was attending school without difficulty, she seemed sullen and withdrawn to her teachers. Lucy had friends at school, but would communicate with them by writing messages on paper or drawing letters in the air. Although Lucy had passed first grade on the basis of her written work, her parents worried about her ability to succeed in second grade, where her teachers expected her to participate in class and she would need to take standardized tests that required audible verbal responses. At the urging of a school counselor, Lucy’s parents took her to their family physician. They needed help in drawing her out so that the rest of the world could get to know the Lucy that they knew and loved.

Lucy’s case is typical of selective mutism

Lucy was suffering from selective mutism, the persistent failure to speak in specific social situations where speaking is expected, such as at school and with playmates.1 Lucy’s case is typical in that children with selective mutism speak well in other situations, typically at home. Thus, the disorder is not due to a communication disorder such as stuttering and it is not due to a lack of knowledge or comfort with language.

To meet diagnostic criteria, the disorder must last at least 1 month, though it can last for several years, and must interfere with a child’s education or ability to communicate socially.1

A little known disorder makes national headlines

Selective mutism occurs in 0.2%–2.0% of children, affects boys and girls equally, and often begins at 3 to 6 years of age.2-9 The disorder gained national attention this past spring when it was revealed that the shooter in the Virginia Tech massacre—Seung-Hui Cho—had, as an adolescent, been diagnosed with selective mutism.10 Though his diagnosis made plenty of headlines, the disorder itself occupies little space in the pediatric literature.11

What we do know is that selective mutism can have a chronic course that affects a child’s ability to form friendships, complete academic tasks, develop appropriate language and social skills, and participate in standardized testing.2-9 While parents often attribute their child’s behavior to shyness, this disorder goes beyond that. While shy children function, those with selective mutism struggle socially, emotionally, and academically. Children with selective mutism say the words won’t come out and their body won’t let them speak. One father of a 7-year-old girl with selective mutism said that his daughter “describes it as the words get stuck in her toes.”12

Many researchers theorize that children with selective mutism have severe social anxiety, and assessment and treatment strategies are typically based on this notion. Reports in the literature have also suggested that selective mutism is related to a developmental disorder or delay, as seen in autistic spectrum disorders, as well as anxiety disorders and depression.13 In addition, selective mutism has been linked to oppositional defiant disorder and subtle language impairments.14,15

Begin by excluding competing explanations

If a family is referred to you for possible selective mutism, you’ll first need to exclude competing explanations for the problem, such as hearing difficulties, speech and language disorders, school-based threats, and medical problems, such as asthma, which could prevent a child from speaking comfortably in a public setting. Assuming you are able to exclude these, and other competing explanations, you’ll need to ask 8 questions of parents and school officials. The answers you get will help you to screen for selective mutism and identify key antecedents and consequences to the behavior that are important in addressing the problem.

8 questions you’ll need to ask

1. What specific settings involve failure to speak? Children with selective mutism typically have difficulties in school, on the playground, in malls, and at restaurants.

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