Paeds · mental-behavioural-and-psychosomatic
Selective mutism
Also known as Selective mutism · Elective mutism (historical) · SM · Social anxiety mutism
Fellowship guide to selective mutism: recognising the child who speaks at home but freezes silent at school, the anxiety-driven freeze (not defiance), DSM-5-TR diagnosis from multi-informant history, the hearing-first differential, behavioural-intervention-first care (stimulus fading, shaping, school collaboration) with SSRI for moderate-to-severe, long-term outcomes and exam pearls.
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Target exams
Red flags
- Acute, complete loss of speech with social withdrawal or developmental regression — reconsider the diagnosis; exclude trauma/abuse, neurological disease and a psychotic or autistic-spectrum process rather than labelling it selective mutism
- Suspected abuse, neglect or a safeguarding concern driving the silence — address safety before titrating behavioural interventions or an SSRI
- Suicidal ideation, self-harm or a sharp drop in mood alongside the mutism — treat the crisis first; do not start an SSRI into an unassessed suicidal landscape
- Focal neurological signs, new seizures, cognitive decline or an atypical course — exclude an acquired neurological or communication disorder
- The child is essentially mute in EVERY setting including home — that is not selective mutism; reassess for a pervasive communication disorder, hearing loss or aphasia
- Marked educational collapse, complete peer isolation or family distress — escalate care intensity rather than reassuring that the child will 'grow out of it'
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Developmental and behavioural paediatrics
- Child and adolescent mental health
- Selective mutism and childhood anxiety presentations
- Current 2026 PREP curriculum — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 12: Communication with patients, families, and health professionals
- Child and adolescent mental health competencies
- Clinical Applications
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 5. Professional skills and knowledge: Health promotion and illness prevention
- General Paediatrics: Assesses mental health and behavioural concerns and initiates appropriate management
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Mental and behavioural disorders
- Clinical
- History
- Communication
- Mental health and behavioural assessment
- General Pediatrics Content Outline — Domain 15: Mental and Behavioral Health
- General Pediatrics Content Outline — Domain 4: Developmental and Behavioral Pediatrics
- General Pediatrics EPA: Assess and manage common mental and behavioural health concerns
- Patient Care 1: History and Physical Examination
- Patient Care 4: Clinical Reasoning
- Medical Knowledge 1: Clinical Knowledge
- Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
- Systems-Based Practice: coordination with mental health and school systems
- Medical Expert
- Communicator
- Collaborator
- Pediatrics: Foundations EPA — Assessing growth and development
- Pediatrics: Core EPA — Managing common mental and behavioural health problems
Overview & Definition
The parent who tells you "she never stops talking at home, but the teacher swears she has never heard her voice all year" is describing the single most recognisable feature of selective mutism. The child is not being difficult, and the silence is not a choice — it is a freeze response in the same anxiety family as social anxiety disorder. Recognising the pattern is the gateway that turns a child labelled "just shy" or "naughty" into one who gets effective treatment. [14] [15]
Selective mutism sits within the anxiety disorders rather than the communication disorders in DSM-5-TR because its core driver is fear of social evaluation, not a deficit in the mechanics of speech. The child typically speaks normally — often loudly and freely — to close family at home, then cannot produce speech when the social-evaluative demand rises, as it does with teachers, peers, strangers or clinic staff. The inconsistency across settings is itself diagnostic and distinguishes selective mutism from a hearing loss or a developmental language disorder. [14] [11]
The clinical habit that matters most is to ask about speech in every setting. A parent's "she's just shy" almost always hides a child who has not spoken at school for months. Pair the parent report with a teacher report, because the diagnosis lives in the gap between what the child does at home and what the child does in the demanding social setting of the classroom. [14] [3]
References15ShowHide
- [1]Black B; Uhde TW Treatment of elective mutism with fluoxetine: a double-blind, placebo-controlled study Journal of the American Academy of Child and Adolescent Psychiatry, 1994.PMID 7961338
- [2]Black B; Uhde TW Psychiatric characteristics of children with selective mutism: a pilot study Journal of the American Academy of Child and Adolescent Psychiatry, 1995.PMID 7649954
- [3]Bergman RL; Piacentini J; McCracken JT Prevalence and description of selective mutism in a school-based sample Journal of the American Academy of Child and Adolescent Psychiatry, 2002.PMID 12162629
- [4]Dummit ES 3rd; Klein RG; Tancer NK; Asche B; Martin J Fluoxetine treatment of children with selective mutism: an open trial Journal of the American Academy of Child and Adolescent Psychiatry, 1996.PMID 8935208
- [5]Cohan SL; Chavira DA; Stein MB Practitioner review: Psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 1990-2005 Journal of child psychology and psychiatry, and allied disciplines, 2006.PMID 17076747
- [6]Kopp S; Gillberg C Selective mutism: a population-based study: a research note Journal of child psychology and psychiatry, and allied disciplines, 1997.PMID 9232472
- [7]Remschmidt H; Poller M; Herpertz-Dahlmann B; Hennighausen K; Gutenbrunner C A follow-up study of 45 patients with elective mutism European archives of psychiatry and clinical neuroscience, 2001.PMID 11881843
- [8]Oerbeck B; Overgaard KR; Stein MB; Pripp AH; Kristensen H Treatment of selective mutism: a 5-year follow-up study European child and adolescent psychiatry, 2018.PMID 29357099
- [9]Oerbeck B; Stein MB; Pripp AH; Kristensen H Selective mutism: follow-up study 1 year after end of treatment European child and adolescent psychiatry, 2015.PMID 25267381
- [10]Oerbeck B; Johansen J; Lundahl K; Kristensen H Selective mutism: a home-and kindergarten-based intervention for children 3-5 years: a pilot study Clinical child psychology and psychiatry, 2012.PMID 21852320
- [11]Yeganeh R; Beidel DC; Turner SM; Pina AA; Silverman WK Clinical distinctions between selective mutism and social phobia: an investigation of childhood psychopathology Journal of the American Academy of Child and Adolescent Psychiatry, 2003.PMID 12960706
- [12]Koskela M; Ståhlberg T; Yunus WMAWM; Sourander A Long-term outcomes of selective mutism: a systematic literature review BMC psychiatry, 2023.PMID 37875905
- [13]Manassis K; Oerbeck B; Overgaard KR The use of medication in selective mutism: a systematic review European child and adolescent psychiatry, 2016.PMID 26560144
- [14]Hua A; Major N Selective mutism Current opinion in pediatrics, 2016.PMID 26709680
- [15]Black B; Uhde TW Elective mutism as a variant of social phobia Journal of the American Academy of Child and Adolescent Psychiatry, 1992.PMID 1342579