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Selective mutism (SM) is a condition which develops during childhood where a child who is fluent with language frequently
fails to speak in specific situations where language is necessary. Selective mutism is a relatively rare diagnosis, and, despite
current research efforts, there is still much to be learned about the nature of the disorder. This condition is most common
among young children (usually before the age of 5).

Generally, at home children affected by the disorder behave like typical children, but in social situations, especially at school,
they are silent and withdrawn. They might talk to grandparents but not to other relatives; they might whisper to one other child,
or talk to no one. Some do not point, nod or communicate in any other way.

Consequently, due to the low incidence in reports of SM most experimental research is dependent on case studies. Further,
many contradicting information and unresolved results in the description of people with SM also exist. Some believe that the
silence occurs only in unfamiliar settings which may also include places in the community. There are accounts of children who
refuse to speak in unfamiliar social settings or in the presence of strangers. Other reports state that these children may limit
their speaking to only a select few individuals, usually parents and/or siblings.

Signs and Symptoms:

•        A constant refusal to speak in one or more social settings which includes school.

•        The behavior interferes with educational, occupational achievement and social communication.

•        The duration of the behavior is at least one month (not including the first month of school).

•        The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in a social
situation.

•        The speech deficiency is not as result of a communication disorder (e.g., stuttering) and does not occur exclusively
during the course of a pervasive developmental disorder.

The main feature in selective mutism is that the child has the ability to both comprehend and speak, but fails to do so in certain
situations. This syndrome differs from mutism because the child sometimes speaks, depending on the circumstances. Children
with mutism never speak.

Cultural issues, such as recent immigration and bilingual speakers, should be considered during the evaluation process. Children
who are uncomfortable with a new language may be reluctant to use it outside of a familiar setting. This is not necessarily
selective mutism, so it should be noted when searching for a diagnosis.

History of Selective Mutism

Recognized as early as 1877 as a disorder, selective mutism was called aphasia
voluntaria at the time by Kussmaul, a German physician who originally described its characteristics. Although the child was able
to speak, he/she willed not to, in Kussmaul’s view. Fifteen years ago, these children were known as elective mutes, and their
silence was seen as willful and manipulative. "If you look at psychiatry textbooks from around 1994," said Dr. Bruce Black, a
psychiatrist in Wellesley, Mass., and an early researcher on selective mutism, "you'll see stated as a fact that these were
stubborn, oppositional kids, and their refusal to speak was a manifestation of that."

Although knowledge about selective mutism has improved and altered in the past 130 years, much still remains unknown and
much of what appears to be known remains unconfirmed. For example, little is known about the long-term course, the efficacy
of intervention, and the very nature of this disorder and documented information is full of varying versions, sometimes
conflicting, in epidemiology.

Another popular belief was that selective mutism was a form of post-traumatic stress disorder. There are stories that these kids
were keeping some secret about something terrible that happened. The truth is the majority of children diagnosed with SM did
not become silent as a result of trauma. Although, many families have said to be suspicious that there child was not talking in
school because they were hiding abuse. The post traumatic stress theory doesn’t hold any validating evidence.

The diagnosis was changed to selective mutism in the fourth edition of the American Psychiatric Association's diagnostic
manual. The important change allows a new perspective on how these children are perceived and treated.

The term selective mutism seems more appropriate than elective mutism, given the onset in research now associating this
disorder with anxiety. Much attention is now directed to learning about the anxiety producing situations that result in the child’s
mutism. Yet, selective mutism is currently classified in the DSM-IV under “Other Disorders of Infancy, Childhood, and
Adolescence,” which some argue this description makes it sound as if a child’s defiance is the source to the unwillingness to
speak.

Incidence of Selective Mutism

Until recently, the disorder was thought to be rare, affecting about 1 child in 1,000. But a 2002 study in The Journal of the
American Academy of Child and Adolescent Psychiatry put the incidence of selective mutism closer to 7 children in 1,000,
making it almost twice as common as autism. However, research on SM does not agree on a single prevalence rate. One reason
for the lack of agreement on prevalence rates is that because SM is so uncommon it is not often studied in large groups or
sample sizes.
Current rates are estimated to be between 3 and 8 in 10,000. Some researchers state that the occurrence of SM is probably
more frequent than this estimate. Reasons for this assumption focus mainly on the possibility of underreporting which could be
due to families living in isolation, a family not recognizing SM as a behavior problem that can be treated, or families being
unaware of the problem altogether since it usually does not occur in the home.

Selective mutism, experts say, it probably represents one end of a spectrum of social anxieties that includes everything from a
fear of eating in public to stage fright and claustrophobia (fear of narrow places). Despite its prevalence, selective mutism is still
widely misunderstood and often ignored. Some children are thought to be shy and parents think they’ll out grow it. Experts say
these children pick up cues in the environment that initiate an adaptive response, which puts them either into a fight-or-flight
situation or leads to a shutdown.

Possible Causes and Risks

Most experts believe that there are environmental, biological, interpersonal, and anxiety related triggers are the cause of selective
mutism. Most children with this condition have some form of extreme social phobia. Some affected children have a family
history of selective mutism, extreme shyness, or anxiety disorders that may increase their risk for similar problems.

Most researchers now agree that selective mutism is more a result of temperament than of environmental influences. In the
early 1990's two studies, by doctors showed that children with the disorder were not just shy; they were actively anxious. They
came to concluding that the kids had social anxiety disorder, and the selective mutism was a display of that. Essentially, other
than the lack of speech, the only common characteristic among the individuals was social anxiety. Researchers conclude that
for this reason, the failure to speak may only be a symptom.

One of the most puzzling aspects of selective mutism is the fact that children stay silent even when the consequences of their
silence include shame, social rejection or even punishment. This problem may be explained by the fact that at the root of the
disorder is the instinct for self-defense, a natural reaction to avoid unpleasant situations. Children with SM will rather refrain
from social interactions. Experts say they don't know how to engage with other people. They learn to avoid eye contact; they
learn to turn their heads and not communicate.

Treatment for Selective Mutism

Current treatment combines behavior modification, family participation, and school involvement. Certain medications that
address symptoms of anxiety and social phobia (extreme social shyness) have been used safely and successfully.

Few doctors are willing to treat selective mutism, and fewer still achieve results. Many now prescribe Fluoxetine, the generic
version of Prozac, for selective mutism, usually combined with cognitive or behavioral therapies. Fluoxetine and other
antidepressants in the class known as selective serotonin reuptake inhibitors, or (SSRI), can loosen inhibitions - a factor in
explaining their usefulness for social anxiety. This also means that they are not for everyone. After starting on antidepressants
some children show improvement in social environments but can begin exhibiting inappropriate behaviors, which end when the
medication is withdrawn.

Selective Mutism is a condition that can last anywhere from several weeks to years. Many parents often think that the child is
simply refusing to speak, but in SM usually the child is truly unable to speak in particular settings. The prognosis for this
disorder varies. However, continued therapy and intervention for shyness and social anxiety into adolescence and adulthood
may be required. Behavioral and cognitive therapies that rely on reducing sensitivity by gradual exposure to distressing
situations, with a lot of positive reinforcement, can also be successful, either on their own or combined with antidepressants.

Clinicians must be careful of labeling children with SM as having speech or language disorders, for this label can misdirect
treatment away from the psychological problems underlying the failure to speak. The best treatments appear to be behavioral
methods implemented in a multidisciplinary setting. Hopefully future research will help in creating a more consistent profile
regarding the prevalence of SM that may contribute to improvements in early detection and early treatment.