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Q&A What is Selective Mutism? - September 2009

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What is Selective Mutism?

By: Joleen Fernald, SLP, Brianne Phillips OTR/L and Chantel Dionne, MS OTR/L

What is Selective Mutism (SM)?

Selective mutism (SM), formerly called elective mutism, is defined as a disorder of childhood characterized by an inability to speak in certain settings (e.g. at school, in public places) despite speaking in other settings (e.g. at home with family). SM is associated with anxiety and may be an extreme form of social phobia according to researchers and clinicians who are familiar with the disorder (Black & Uhde, 1995; Dow et al., 1995, Dummit et al., 1997, Kristensen, 2001; Leonard & Dow, 1995).

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, referred to by clinicians as the DSM-IV, (APA,1994) recognized that the social anxiety and avoidance characteristic of social phobia may be associated with SM, and thus, both diagnoses may be given. More than 90% of children with SM also meet the diagnostic criteria for social anxiety disorder, now termed social phobia (Black et al., 1996).

Diagnosis of other comorbid anxiety disorders are also commonly diagnosed with SM and social phobia (Biedel & Turner, 1998). The name change from "elective" to "selective mutism" in DSM-IV deemphasized the oppositional behavior connotation that a child elected not to speak and rather emphasized the characteristic of the disorder, that there are select environments in which speaking does not occur (APA, 1994). The term selective mutism is consistent with new etiological theories that focus on anxiety issues (Dow et al., 1995).

The current edition, DSM-IV-TR (APA, 2000) states that the following criteria must be met in order to qualify for a diagnosis of selective mutism:

An inability to speak in at least one specific social situation where speaking is expected (e.g., at school) despite speaking in other situations (e.g., at home); The disturbance has interfered with educational or occupational achievement or with social communication; The duration of the selective mutism is at least one month and is not limited to the first month of school; The inability to speak is not due to to a lack of knowledge of or discomfort with the primary language required in the social situation; and, The disturbance cannot better be accounted for by a communication disorder (e.g. stuttering) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder.

Consistent with current research, SMG believes that Selective Mutism is best understood as a childhood social communication anxiety disorder. SM is much more than shyness and most likely on the spectrum of social phobia and related anxiety disorders. SM is NOT a child willfully refusing to speak.

Who evaluates and treats SM?

Evaluating and treating children with SM really requires a multi-disciplinary team approach. Because SM is a social communication anxiety disorder, professionals with expertise in social communication (Speech-Language Pathologists) and anxiety (mental health treating professionals such as Licensed Clinical Social Workers, Clinical Psychologists, or Psychiatrists) are suggested. Moreover, occupational therapists should also assess and treat the child’s sensory processing and motor skills.

Specifically, what role does a SLP play in assessing and treating SM?

SLPs evaluate social pragmatics in children with SM. Research is showing a high prevalence (approximately 30%) of children with SM also have speech and language difficulties. In addition to the social communication challenges, children with SM often have articulation and syntax difficulties. They struggle with organization and sequencing which also impacts motor planning and the ability to complete activities of daily living.

What assessment tools do SLPs use in evaluating children with SM?
  • CELF-4 / CELF-P2 including the Pragmatics Rating Scale
  • Social Skills Rating System
  • PPVT -4
  • EVT-2
  • Language Sample Analysis

What role does an OT play in assessing and treating SM?

OT's look at the child's sensory processing and regulation abilities, gross motor and fine motor skills and how these skills impact their functional independence in play, at school and in the community.

What are the most common types of sensory processing difficulties you observe in kids with SM?

All children/people have sensory preferences and needs. This is the same for children with SM as well. Children with SM often times are withdrawn and may miss out on sensory experiences in their development. Often times these children may seek out their sensory needs when they are in a comfortable environment (home, grandma's house, etc.)

What programs may be useful in treating kids with SM?
  • Therapeutic Listening
  • How Does your Engine Run
  • Stickkids
  • Yoga
  • Handwriting without Tears,
  • Movement and Play Based Therapy

What assessments do OTs use to assess kids with SM?
  • Sensory Profiles (caregivers questionnaire, infant/toddler, or adult/adolescent)
  • School Sensory Profile
  • Visual motor assessment to include (Beery VMI, WRAVMA)
  • Peabody (GM and FM assessment for children under 5)
  • Clinical observations
  • Parent interview
  • ADL Checklist

This Month's Featured Authors Joleen Fernald, MS, CCC-SLP, Brianne Philipps, OTR/L and Chantel Dionne, OTR/L

Ms. Fernald, Ms. Philipps, and Ms. Dionne are all from Easter Seals NH, The Family Place. Visit their website at

Joleen Fernald, CCC-SLP is currently a PhD student studying infant mental health and developmental disabilities with Dr. Stanley Greenspan. She has a special interest in the social emotional development of young children. As a speech-language pathologist, Joleen works with children with a variety of communication disorders. She has partnered with Easter Seals NH to begin an assessment and treatment clinic specifically for selective mutism, a social communication anxiety disorder and is currently the Chair of the Selective Mutism Group, a non-profit organization specializing in the advocacy of Selective Mutism awareness. Joleen enjoys public speaking and has presented nationally on the topics of childhood apraxia of speech and selective mutism. To learn more about Selective Mutism visit the SMG website at

Brianne Philipps OTR/L is a licensed occupational therapist working in the field of pediatrics. She graduated from the University of New Hampshire and since then has worked in a variety of pediatric settings including early supports and services, schools, and outpatient clinics. Bri uses a holistic approach in working with children and families, drawing from different theories of practice. She has a strong foundation in Sensory Integration and is certified in the Therapeutic Listening Program. Bri facilitates Kid Connect and coordinates the Camp Connect program for children on the Autism Spectrum. She is a Certified Pediatric Yoga Instructor, participates in the Aquatic Therapy program, and is an evaluator for The Selective Mutism Clinic.

Chantel Dionne MS, OTR/L is a pediatric occupational therapist working for Easter Seals New Hampshire. She completed her Master’s degree in Occupational Therapy at the University of New England in Biddeford, Maine. She has experience working with diverse populations including children and adults in a rehabilitation setting, large preschool based setting, and center based early intervention. As an occupational therapist, she currently practices as a family centered pediatric clinician and works to facilitate social communication groups for children with various abilities. She has assisted with groups geared towards social communication anxiety disorders. She holds certifications in Pediatric Yoga and Therapeutic Listening. She enjoys diversity in her work, including aquatic therapy and volunteering with an adaptive ski program.

Tags: Q&A Selective Mutism OT SLP Newsletter September 2009 Article