Selective Mutism: Causes and Interventions

ALAN M. HULTQUIST

ELECTIVE

MUTISM

(FORMERLY

called elective mutism) is a relatively rare disorder affecting less

than 1% of the clinical population
(American Psychiatric Association
[APA], 1994), although some researchers believe it is underreported (Hayden,
1980; Lesser-Katz, 1986). Two epidemiological studies reported in Tancer
(1992) found prevalence rates in the
normal population of 0.66 to 0.8 per
1,000 after age 5, and 7.2 per 1,000 at
age 5. However, Hesselman's (1983)
review of 115 years of selective mutism
literature led him to conclude that such
rates are too low. Selective mutism occurs somewhat more among girls than
boys (APA, 1994; Barlow, Strother, &
Landreth, 1986; Hayden, 1980; Tancer,
1992; Wergeland, 1980), and the current diagnostic criteria in the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV;
APA, 1994) consist of five factors:

1. A persistent lack of speech in some

social situations but not in others;
2. Interference with academic or occupational achievement or social communication;
3. A duration of at least 1 month (but
this cannot be the first month of
school);
4. A cause that is something other than
discomfort with or ignorance of social language; and
5. The elimination of other possible
causes, such as a communication disorder, pervasive developmental delay, or a psychotic disorder.
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Selective mutism is characterized by a persistent lack of speech in some social situations but not in
others. One of the most common settings where selective mutism occurs is the school. This article
reviews some of the published literature regarding the causes, assessment, and treatment of selective
mutism in school-age children. The most successful treatments have included various forms or
combinations of behavior modification. However, a strict behavioral approach may not be the best
method to use, offering only the illusion of success while underlying problems may still remain.

These five criteria are a substantial

change over those listed in the DSMIII-R (APA, 1987). However, despite
the addition of the new criteria, there
is still just one basic symptom: a lack of
speech. These children tend to learn
normally and to interact with their
peers, albeit nonverbally (Lumb &
Wolff, 1988). This article will review
information regarding possible causes
and treatments for selective mutism.
(For more extensive reviews of the literature, readers are referred to Cline &
Baldwin, 1994, and Kratochwill, 1981.)

to unfamiliar situations or people by

withdrawing.
Lesser-Katz is not alone in offering
alternative or elaborated labels for children with selective mutism. For example, Golwyn and Weinstock (1990)
and Black and Uhde (1992) reported it
to be a symptom of social phobia.
Crumley (1990) also noted this as a
possibility in his discussion of a subject
who described panic attacks and a fear
of saying something that would be embarrassing as being associated with his
childhood mutism.
Subgroups

ASSOCIATED DISORDERS,
SUBGROUPS, AND CAUSATIVE
FACTORS
Associated Disorders
There is disagreement regarding whether
selective mutism is a separate problem
or a symptom of some other disorder
(Krolian, 1988). Lesser-Katz (1986)
believes a single symptomin this case,
silencedoes not present itself in isolation. Instead, she views selective
mutism as a symptom of stranger reaction. In this condition, children react
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Various attempts to identify and label

specific subgroups of children with selective mutism have been made
(Wright, Miller, Cook, & Littman,
1985). One such classification system,
developed by Hayden (1980), provides
a detailed list of subgroup characteristics, along with probable causes for the
mutism found in each group. His categories appear to be the most specific
and are inclusive of those subtypes identified by others (Wright et al, 1985).
Hayden (1980) studied 68 children
with selective mutism from the U.S.
West and Midwest. The children's ages

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ranged from 3 years 9 months to 14

years 4 months, and they represented
various ethnic and socioeconomic
groups, Hayden obtained information
about the children through observation,
video- and audiotapes, written reports,
and questionnaires, along with various
school and psychological reports. Based
on the resulting information, Hayden
identified four subtypes: symbiotic,
speech phobic, reactive, and passiveaggressive.
Symbiotic mutism was identified by
Hayden as the most common of the
subtypes. Children with this subtype had
a symbiotic relationship with their
mother, who was dominant and verbal,
whereas their father was passive, nonverbal, or absent. Hayden described
these children's mothers as "consistently
[meeting] all the child's needs
and . . . often openly jealous of the
child's other relationships, especially
outside the home." The mute child, on
the other hand, "was negativistic in his
or her behavior toward controlling
adults and situations [and the silence
seems] to serve a highly manipulative
purpose" (1980, p. 123).
The second type of selective mutism
found by Hayden, speech phobic, was the
least common of the four. Children displaying this subtype had a fear of hearing their own voices, displayed ritualistic
behavior around speech, and were motivated to regain speech. They also were
more likely than any of the other subtypes to use nonverbal communication.
Fifty-seven percent of the children with
speech phobia had been warned not to
disclose certain information about the
family.
In the third subtype group, reactive
mutism, the child's reluctance to speak
"was precipitated by a single or a series
of traumatic events; such as rape, mouth
or throat injuries, or being told to 'shut
up and never open your mouth again'"
(Hayden, 1980, p. 125). All the children in this group also displayed symptoms of depression.
Passive-aggressive mutism, the fourth
category, "was characterized by using
silence as a weapon, expressing clearly
albeit silentlyhostility by defiant refusal to speak" (Hayden, 1980, p. 126).
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These children also displayed frequent

and sometimes violent antisocial behavior. Children with passive-aggressive
mutism were usually the scapegoats of
the family, and the home environment
was frequently pathogenic; therefore,
Hayden viewed the children's mutism
as an attempt to control and manipulate the world in some way.
The general characteristics of all
these subtypes included physical tension, rigidity, fearfulness, and nervous
habits. Additionally, all the children,
except those in the passive-aggressive
group, were shy and clinging away from
home but demanding and stubborn at
home. Of the four subtypes, only those
children classified as having reactive
mutism showed signs of definite withdrawal.
Causative Factors
The possible causes for selective mutism
found in the literature are numerous.
Hayden (1980) reported that all the
families in his study had substantial
pathology, for example, child abuse. In
addition, Louden (1987) and Krohn,
Weckstein, and Wright (1992) reported
such family factors as parental use of
silence to display hostility, pathological shyness or anxiety in parents, and
marital discord as being associated with
selective mutism.
Lesser-Katz, 1986; Pustrom and
Speers, 1964; and Wergeland, 1980 also
reported some of the same causative
factors as Hayden (1980). In addition,
some researchers have attributed selective mutism to a variety of different
factors:
1. Learned and/or attention-seeking
behavior (Friedman & Karagan,
1973; Reed, 1963);
2. Fixation at an early stage of psychosexual development (Silverman
& Powers, as cited in Colligan,
Colligan, & Dilliard, 1977);
3. Fixation on or regression to behavior that is normal in younger children who have stranger anxiety
(Lesser-Katz, 1986);
4- Displaced hostility (Elson, Pearson,
Jones, & Schumacher, 1965);
5. An attempt to protect a precarious

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6.

7.
8.
9.

10.

self-image (Halpern, Hammond, &

Cohen, 1971);
A child's need to control aggressive and destructive fantasies
(Halpern et al., 1971; Wergeland,
1980);
An aspect of social phobia (Black
& Uhde, 1992; Crumley, 1990);
A failure of socialization (Youngerman, 1979);
A failure of normal language development between mother and
child during the first 2 years of life
(Krolian, 1988); and
Impoverished maternal language
(Krolian, 1988).

Others, however, have found no conclusive cause for this disorder (Kolvin
& Fundudis, 1981; Golwyn & We instock, 1990). It therefore appears that
there may be many different causes for
selective mutism, and more than one
factor might be involved in the development of this disorder in any particular child.
As Tancer (1992) pointed out, studies and discussions of selective mutism
include a heterogeneous group of children. The fact that this disorder is characterized by just one symptom allows
for the inclusion of children with other
possible co-occurring disorders, such as
social phobia or stranger reaction, and
the possibility for varied etiologies. At
this time, there is no consensus regarding causes and subtypes or the possibility that selective mutism is simply a
sign of some other disorder.
AGE OF ONSET AND REFERRAL
The early onset of selective mutism is
well documented. It usually begins before age 5 (APA, 1994; Kratochwill,
Brody, & Piersel, 1979; Krohn et al.,
1992; Pecukonis & Pecukonis, 1991;
Tancer, 1992; Wergeland, 1980; Wright
et al., 1985) and in most instances lasts
only a few months (APA, 1994; Louden,
1987; Tancer, 1992). However, some
authors have identified an adolescent
selective mutism similar to Hayden's
(1980) passive-aggressive subtype
(Kaplan & Escoll, as cited in Wright et
al., 1985).

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therapy, and occupational therapy lasting from 8 months to 4 years. However,

the mutism in the cases where these
therapies were used did not disappear
in all instances. Wergeland believes
psychoanalytical therapy with mute
1. Speaks occasionally to most persons children can be demanding and lengthy,
in most test environments;
as well as exasperating and intolerable
2. Speaks to only one or a few persons for some therapists. Such reactions most
in most test environments;
likely result because the mute child does
3. Speaks to most persons in only one not participate in the basic component
of most psychodynamic approaches:
test environment;
4. Speaks to only one or a few persons talking. However, even silence can be
in only one test environment; or
a form of communication (Krolian,
5. Does not speak to anyone in any 1988), and Youngerman (1979) made
use of that silence and the accompanytest environment.
ASSESSMENT AND TREATMENT
ing nonverbal communication in his
Based on the outcome of the behav- work with an adolescent boy who had
Assessment
ioral assessment, Labbe and Williamson been selectively mute for more than 10
Once a child is referred, an assessment suggested a specific series of behavioral years. Youngerman was successful both
needs to be conducted and the ques- interventions.
in reducing the therapeutic frustration
tion of what treatment(s) to initiate
In addition, with selective mutism he felt due to the boy's silence and in
needs to be answered. The traditional there is perhaps an increased need to increasing the effectiveness of the
psychoeducational assessment process include outside sources (e.g., teachers, therapy by switching to nonverbal in(e.g., cognitive, emotional and behav- paraprofessionals, parents) in the assess- teractions (e.g., facial expressions, mime,
ioral, and academic performance) may ment process. These outside sources are gestures, note writing), initially to the
not always be possible with a child who important not just for the assessment; exclusion of speech.
is selectively mute due to the lack of they can also play a part in the interKrolian (1988) described successful
expressive language. However, such vention, depending on which type is interventions with two children using
approaches may be necessary to rule out chosen. Psychodynamic interventions; a day hospital environment. However,
possible language-based disorders or inpatient hospitalization; milieu, play, although Krolian interpreted the
other diagnoses.
family, drug, or speech therapy; parent children's behaviors from a psychoBaldwin and Cline (1991) offered counseling; and behavior modification dynamic perspective and although psyan extensive discussion of assessment have all been reported (see the follow- chotherapy was one component of the
in selective mutism. They pointed to ing discussion).
treatments, other factors were involved,
the need to explore family and develIt is questionable as to whether in- such as behavioral interventions, that
opmental histories. In addition, they tervention is necessary with all chil- most likely influenced the therapy outbelieve that it is necessary to examine dren who are selectively mute. Although come.
the current situation in terms of how Wergeland (1980) reported evidence of
Some therapists have found play
much and to whom the child speaks in spontaneous remission (following a therapy to be effective. Weininger
particular situations and to explore three change of environment), Hayden (1980) (1987) provided a detailed account of
possible themes: the meaning of com- noted the opposite. He stated that such two case studies in which individual
munication for the child, the way si- remission is rare and is mostly restricted play therapy was effective in restoring
lence might be helping the child to to mild instances of symbiotic mutism, speech to two first-grade girls; Barlow
control certain situations, and what role, and that children who have such a re- et al. (1986) used sibling play therapy
if any, anxiety plays. Baldwin and Cline mission stop talking again later. These with a 5-year-old girl. The latter realso discussed the need to assess: discrepancies raise the important issue searchers believe that play therapy of(a) the environment to discover any of whether there are significant differ- fers a safe environment with no pressure
persons or factors that might be help- ences between transient and persistent for speech and allows the child to coming maintain the mutism, (b) the non- mutism that may hold important impli- municate in a comfortable manner.
verbal communications that are engaged cations for treatment (Tancer, 1992).
Pustrom and Speers (1964) combined
in by the child or that elicit a response This question has yet to be addressed. play therapy for three children with
from the child when used by others,
selective mutism with therapy for the
and (c) family members for factors other Psychotherapy
children's mothers. They noted that
than the mutism that might be of pri- Wergeland (1980) discussed inpatient having the therapists interpret to the
mary concern to them.
and outpatient psychotherapy, milieu children the feelings they were depictAccording to the DSM-IV, adults
may not notice the mutism until the
children enter school. However, the
classroom expectation for speech, and
these children's failure to comply, is
not always enough to prompt a rapid
referral. Referral ages span a range from
5 years to 11 years (Hayden, 1980;
Krohn et al., 1992; Wergeland, 1980;
Wright et al., 1985), and an examination of the literature indicates that some
children have been mute during 8 years
of school before a referral occurs.

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Labbe and Williamson (1984) also

discussed the need to assess a child's
verbal behavior in varied situations.
They indicated five possible outcomes
from such an assessment: a child who

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ing in play was a successful technique.

However, none of the children ever
spoke to the therapists, even though
they did speak to others. Although this
result seems to be a common occurrence in psychotherapy approaches
(Lumb & Wolff, 1988), it is not always
present (Afnan & Carr, 1989).
Wergeland (1980) noted that children treated by psychoanalysis at the
University of Oslo showed improvement
when a change was made in the environment so that the child no longer
had to fulfill the expectation of not
speaking. He therefore advocated a
change of school whenever possible as
the first therapeutic step. Although
Nolan and Pence (1970) reported on a
girl who improved in her willingness to
speak but still did not talk to most of
the adults who had known her to be
mute, this type of response seems to be
the exception. Other researchers (e.g.,
Colligan et al., 1977) have indicated
that children have changed schools with
no effect on their mutism. In addition,
after years of mutism, many children
have been successfully treated and begun to speak normally without the drastic measure of changing institutions.
Family Therapy
Due to the possible co-occurrence of
family dysfunction w i t h selective
mutism, family therapy may be a necessary intervention component. Lazarus,
Gavilo, and Moore (1983) reported on
the effective combination of family
therapy using Murray Bowen's theory
and behavior modification by a school
psychologist in the case of a 7-year-old
girl. In this instance, the family therapy
consisted of three 1 -hour sessions aimed
at clarifying family relationships and
helping each member to develop an
identity outside the family group.
Carr and Afnan (1989) used family
therapy in addition to individual play
therapy. The subject in this study was a
6-year-old girl who had been selectively
mute for 4 years. In this instance, family therapy involved only the parents
and was aimed toward the development
and supported implementation of a
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volving the mother, coupled with reinforcement at home.

D r u g Therapy
In a pharmacological approach to selective mutism, Golwyn and Weinstock
(1990) successfully treated a 7-year-old
girl with the antidepressant phenelzine.
These authors view selective mutism as
being similar to anxiety disorders in
adults, and they noted that phenelzine
has been successful in making adults
with social phobia talkative. T h e treatment lasted 24 weeks; 5 months after it
ended, the mutism had not returned.
Black and Uhde (1992), who view
selective mutism as a symptom of social
phobia, successfully treated a 12-yearold girl with the drug fluoxetine. Previous p s y c h o t h e r a p y and b e h a v i o r a l
interventions had been unsuccessful
with this student. The girl, who had
not spoken at school before the initiation of drug therapy, began to talk to
peers and adults, participated in oral
presentations, and volunteered answers.
In one of the few studies of selective
mutism to make use of a control group,
Black and Uhde (1994) used either
fluoxetine or a placebo with 15 selectively mute children for 12 weeks. Differences between the groups were mostly
nonsignificant; however, parents did rate
those subjects receiving fluoxetine as
showing significantly more improvement in their mutism. Teacher and clinician ratings were nonsignificant. In
addition, "treatment effects were modest and most of the subjects were still
significantly impaired at the end of the
study period" (p. 1005). There were
indications that a longer treatment period may produce more beneficial results.
Behavior Modification
The most commonly used treatment for
selective mutism is some form of behavior modification, such as contingency management, stimulus fading,
shaping, desensitization, extinction,
aversion, and various combinations of
these approaches. Self-modeling has also
been combined with behavioral approaches.
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Contingency Management* AlbertStewart (1986) used a token economy

system in an outpatient clinic to improve the oral language skills of a 13year-old boy who had been selectively
mute at school for 8 years. For 11 sessions, the boy read into a tape recorder
and was rewarded for the volume and
clarity of his speaking. After these sessions, with encouragement from his
teacher and classmates, he was able to
increase the quantity of his speech in
school. It should be noted, however,
that he was not totally mute, but instead engaged in occasional whispering
and monosyllabic utterances.
Calhoun and Koenig (1973) reported
success with the use of class-wide rewards contingent upon verbal exchanges
between teachers and students. The students in this case were eight children
in Grades K to 3 from bilingual, nonW h i t e backgrounds. These children
were discouraged from using their primary language at school and were referred because of "grossly deficient or
absent verbal behavior directed to adults
in the classroom" (p. 700).
Because speech was not completely
absent in these two just cited studies,
they perhaps would be more appropriately classified in terms of reluctant
speech, which was described by Williamson, Sewell, Sanders, and Haney
(1977). Although these studies used
contingency management as the sole
behavioral technique, it is more frequently combined with other behavior
modification methods.
Stimulus Fading* In a case of stimulus fading, Conrad, Delk, and Williams
(1974) reported on an 11-year-old girl
who had not spoken at school for 5
years. Their program required 12 sessions and at the beginning involved
tangible reinforcers. T h e first session
took place in the child's home with her
mother and a mental health worker
present. In this session, the girl was rewarded when she orally responded to
arithmetic flash cards presented by the
mental health worker. Sessions 2 and 3
were similar except the mother was not
present and the reinforcement schedule changed from continuous to fixed

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ratio. The therapy sessions then moved

to a clinic, where a classmate was present
along with the mental health worker.
Next, the girl's teacher was added to
the sessions and given the responsibility of presenting the stimuli. At this
time, a point system replaced the tangible reinforcers. The next step along
the continuum moved the child to her
classroom where five classmates, the
teacher, and the mental health worker
were in attendance. The entire class
was present for the final sessions.
Shaping* Rosenbaum and Kellman
(1973) studied the use of shaping to
elicit speech from a third-grade girl. In
this case, the program began in the
speech/language room and slowly moved
to the classroom through a series of
successive approximations. Speech was
initially established in a one-to-one
setting, then classroom elements (i.e.,
reading book, teacher, students) were
gradually introduced into the speech
room. At the same time, the student's
voice was "introduced" into the general education classroom. This introduction began with a tape recording of
the girl reading from her text being
played to her reading group while the
girl was present. Then recordings were
made of the child's interactions with
classmates during reading activities in
the speech room, and these recordings
were played back in the classroom. At
this point, the girl began to participate
spontaneously in reading class. By the
end of the treatment, the student was
participating in all aspects of school
work, dominating some conversations,
and singing and performing skits in class.
Desensitization* Desensitization was
successfully used as a therapeutic intervention in Rasbury's (1974) study of an
11-year-old girl who had been selectively mute for 6 years. After play
therapy had been tried to no effect,
desensitization was used. In this case,
the girl's speech decreased in intensity
and quantity as her father drove closer
and closer to school each morning. By
the time they reached school, the girl's
speech had stopped. The treatment required her to read orally sentences
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printed on index cards while she traveled to school. The cards described
school events and if she read them all
(and later read them in a normal tone
of voice), she was allowed to choose
one of the activities in which to participate that day. This procedure took
the girl through a hierarchy of 15 steps
that involved getting her to speak both
to other people and the closer she got
to school.
Another desensitization study (Reid
et al., 1967) took place in 1 day at a
clinic. When prompted every 30 seconds by her mother, a 6-year-old girl
had to ask for food while a stranger
moved progressively closer to them. The
next step involved the stranger telling
the mother to ask the girl to request
food and then moved on to having the
stranger ask the girl directly if she
wanted food. Gradually more adults and
two children were introduced under
similar circumstances. Follow-up sessions showed improved speech.

was established in the clinic setting,

the sessions moved to the school. Videotaping of each session occurred while
the stimulus fading procedures were taking place in the clinic. Before the move
to the next step in the stimulus fading
procedure, the girl watched her successful verbalizations from the previous
sessions. By making use of the selfmodeling procedure in this way,
Holmbeck and Lavigne eliminated the
need for videotape editing. Once the
therapy moved to the school, contingency management was added and rewards were provided for success in
progressively more difficult verbal tasks.

Extinction and Aversion. Some

studies have relied on extinction
(Dmitriev & Hawkins, 1974) or aversion (Van Der Kooy & Webster, 1975)
to eliminate mutism in school-age children; however, the use of these interventions raises the issue of professional
ethics. Because the techniques employed
in these studies could be considered
Self-Modeling. Other successful abusive, one must ask whether the end
treatments have involved behaviorism justifies the therapeutic means.
Not all such approaches may be abuand social learning through selfmodeling. Pigott and Gonzales (1987) sive. Watson and Kramer (1992) used a
videotaped a child answering questions shaping program that combined posiin class while members of his family tive reinforcement, mild aversives, and
were off camera. Kehle, Owen, and extinction in the school setting along
Cressy (1990) taped a child answering with shaping, stimulus fading, and mild
questions directed at him by his mother punishment at home and in the comand not answering the same questions munity. It should be noted that careful
posed by his teacher. In each case, the consideration and constant monitoring
tapes were edited to show proper need to accompany any use of extincteacher-child interactions in the class- tion or aversion, and professionals
room. The children viewed the videos should not make either of these techdaily and were reinforced each time niques their primary intervention.
Although lacking the specificity of
verbal interactions occurred on the tape.
Holmbeck and Lavigne (1992) com- the studies mentioned above, Friedman
bined stimulus fading and self- and Karagan's (1973) discussion deserves
modeling in their work with a 6-year- mention. These authors provided a list
old girl who had been silent at school of seven guidelines for use with chilfor VJ2 years. The treatments began in dren who are selectively mute. These
a clinic and later moved to the school guidelines have as an unstated concern
setting. In the clinic, a therapist was respect for the child and her or his diggradually added to situations where the nity. No matter what treatment apgirl and her mother were talking. After proach professionals choose, such a
the girl was able to converse with the concern must be maintained and intetherapist, a classmate was brought to grated into all aspects of the therapy.
the clinic, followed in subsequent ses- Not all approaches have this composions by another class member and the nent, however. Examples include the
teacher. After speech with the teacher previously cited studies by Dmitriev and
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Hawkins (1974) and Van Der Kooy and

Webster (1975). Another example is
the Hawthorn Center approach described by Krohn et al. (1992). This
approach combines parental education
and involvement, cooperation with the
school, and psychotherapy with the
child. The latter includes a confrontation between the therapist and the child
in which the child is not allowed to
leave the therapy session until speech
occurs. This type of approach is not
respectful of the child and may be
counterindicated because the clinic may
be the last place where speech is likely
to occur, if it occurs there at all (Black
& Uhde, 1994; Kratochwill et al., 1979;
Lumb & Wolff, 1988; Pustrom & Speers,
1964).
SPEECH GENERALIZATION
One of the major problems with studies
of selective mutism is that few offer
specific information regarding the generalization of speech across settings or
individuals. Authors mention that the
children "reportedly [had] no difficulty
speaking to either the teacher
o r . . . peers" (Wright et al., 1985, p.
743); found fun in talking, singing, and
generally participating in class (Barlow
et al., 1986); "began to exhibit spontaneous speech in the presence of nonfamily members" (Rasbury, 1974, p.
104); and other vague statements of
success. However, few have offered
empirical evidence of generalization.
Studies that tried to rectify this problem have been disappointing for the
circumstances under which they measured generalization (Brown & Doll,
1988; Sanok & Striefel, 1979) or for
the amount of information provided
about generalization (Watson &
Kramer, 1992).
In their treatment strategy, Labbe
and Williamson (1984) addressed the
issue of generalization on a more practical level. As noted previously, their
approach involved an initial determination as to how many people the child
spoke to in a variety of environments
and then the incorporation of stimulus
fading and contingency management to
introduce new people and/or new enviJOURNAL

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ronmental elements. Although this approach acknowledges the importance of

environmental conditions in producing
verbal behavior, professionals should
also examine the conditions influencing the types and degree of nonverbal
communication in which the child engages (Frenchette, 1989). This may assist in uncovering the environmental
conditions that help maintain the
mutism. Colligan et al. (1977), Nolan
and Pence (1970), and Van Der Kooy
and Webster (1975) all pointed out that
both teachers and students reinforce
the silence of children with selective
mutism.
CONCLUSION
The question of whether selective
mutism is a separate disorder or is a
symptom of some other problem is an
important one that needs further research. The resulting answers could have
a major impact on the assessment process and the type(s) of intervention
chosen. Assessment of selective mutism
is not discussed in the literature to any
large extent. Further research into the
possibility of subtypes, along with particular causes for differing subtypes and
the best intervention(s) for specific subtypes, would greatly aid the assessment
process.
Although behavioral approaches are
the most common way of trying to
change these children's silence, they are
interventions that work only on a surface level. If the mutism seen in this
disorder is caused by a more severe problem, such as abuse, or if it is a sign of a
more far-reaching disorder, such as social phobia, then treatments that target only the symptom are insufficient.
This is one reason that further studies
are needed to clarify the issue of whether
selective mutism is a monosymptomatic
disorder or an indication of a more severe problem.
Perhaps another reason there are
questions about the nature of selective
mutism is due to a lack of good information regarding generalization and
long-term prognosis. Most reports concern only the mutism and do not explore other social and academic
EMOTIONAL

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BEHAVIORAL

behaviors. In addition, follow-up, when

it is present, is usually brief and does
not typically examine generalization.
More research into these areas would
provide counselors with some idea as to
whether these children continue to
experience problems in new social situations and whether they have generally
good or poor outcomes as adults.
Kratochwill et al.'s (1979) review of
the selective mutism literature included
one study that showed 21% of children
having only fair or poor adjustments
6 months to 7 years after treatment and
another study in which the general
outcome 9 years after treatment "did
not present a picture of good adjustment, academically or socially" (p. 200).
Wergeland (1980) also noted mixed
results regarding general adjustment up
to 16 years after treatment. These results would seem to confirm that for
some children with selective mutism
there is more to the disorder than a
type of specific anxiety, attempts at
manipulation, or a simple learned behavior.
Hayden's (1980) subtypes also indicate that there is more involved with
these children than simple silence and
that there is a need for more than behavioral interventions. Family therapy
and play therapy seem to be logical alternatives or additionsfamily therapy
due to the presence of family problems
in many researcher's reports and play
therapy because it provides young children with the means of communicating
nonverbally.
No matter what intervention is chosen, teachers and therapists need to be
aware that any treatment plan may take
a long time to be effective. Cunningham, Cataldo, Mallion, and Keyes
(1984) noted that spontaneous speech
is most likely to occur when treatment
programs last for extended periods of
time; Krohn et al. (1992) reported interventions lasting for up to 2 years. It
appears that the treatment of selective
mutism requires careful consideration
of numerous factors and a well-planned
generalization process.
Because it is likely that selective
mutism is a disorder with varied etiologies, careful diagnosis and therapy selec-

DISORDERS,

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1995,

VOL.

3,

NO.

^05

tion are important. These processes

would be aided by additional research
that explores whether there are differences between persistent and transient
mutism, as Tancer (1992) has recommended, and by research that compares
the effectiveness of the various treatments. Kratochwill et al. (1979) offered
a good critique of research methodologies found in the selective mutism literature. In addition to their suggestions
on how to improve single-subject research, the exploration of long-term
prognosis, generalization, subtyping,
interventions, and possible interactions
among these areas needs to be addressed
with experimental designs that include
a number of subjects, such as in the
study conducted by Black and Uhde
(1994), rather than the case studies and
single-subject designs that predominate
at present.
About the Author
ALAN M. HULTQUIST received his MEd in
special education from Lyndon State College in Vermont. He is an educational diagnostician currently pursuing a doctorate in
educational psychology at American International College in Massachusetts. Address:
Alan M. Hultquist, RR 3 Box 134B, Barton,
VT 05875-9136.
Author's Note
Appreciation is extended to Reviewer C for
the suggestions and comments.
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