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Ask the Mental Health Expert Archives 2001-2004

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Elective/Selective Mutism

Q. I'm a preschool director with a 4-year-old who will not talk. In 11 years of working with children I've never seen a child react like this. He's been coming to our school for 5 months and has only muttered good-bye when pushed to do so by his parents.

He enjoys school, he laughs at the teacher, interacts in all games and activities, plays with the other kids, has a healthy appetite, and is really affectionate. He just won't talk. When we first consulted the parents they naturally assumed, like everyone else, that it was an attention getting behavior. They asked the staff to be firm and make him talk; it didn't work. We ignored the behavior; it didn't work. Now we just kind of accept him this way and go on about our day with no change from him.

He's a lovely, sweet tempered child, that by the way, talks up a storm at home. I personally think this goes beyond attention getting since it's went on for so long without any real attention for the silence. Can you offer any help?

A. The fact that this child talks up a storm at home suggests that this is a case of so-called elective (or selective) mutism, though other diagnoses are possible. Although some cases of mutism may be associated with underlying brain disease and/or developmental disorders (such as Fragile X Syndrome), most cases of selective mutism appear to be related to social phobic anxiety.

Indeed, Black & Uhde observe that, "Social anxiety is a nearly universal characteristic of children manifesting the syndrome of elective mutism." So, in a sense, the child's mutism is precisely the opposite of an attention-getting maneuver. It is really driven primarily by a fear of social judgment or criticism.

However, in some cases, oppositional traits may also be involved (see Wright et al, J Am Acad Child Adolesc Psychiatry 1995 Jul;34(7):857-62). Selective mutism may respond to various forms of cognitive-behavioral therapy (CBT) and/or Prozac type medications (see Black & Uhde, J Am Acad Child Adolesc Psychiatry 1994 Sep;33(7):1000-6).

I would strongly recommend that this child be evaluated by either a child psychologist or, perhaps preferably, a child psychiatrist, so that appropriate diagnosis and treatment may be started. Good luck!

October 2002

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