Selective Mutism: Causes and Interventions
ALAN M. HULTQUIST
S ELECTIVE MUTISM (FORMERLY
called elective mutism) is a rela-
tively rare disorder affecting less
than 1% of the clinical population
(American Psychiatric Association
[APA], 1994), although some research-
ers believe it is underreported (Hayden,
1980; Lesser-Katz, 1986). Two epide-
miological 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 oc-
curs somewhat more among girls than
boys (APA, 1994; Barlow, Strother, &
Landreth, 1986; Hayden, 1980; Tancer,
1992; Wergeland, 1980), and the cur-
rent diagnostic criteria in the Diagnos-
tic 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 occu-
pational achievement or social com-
munication;
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 so-
cial language; and
5. The elimination of other possible
causes, such as a communication dis-
order, pervasive developmental de-
lay, 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 to unfamiliar situations or people by
change over those listed in the DSM- withdrawing.
III-R (APA, 1987). However, despite Lesser-Katz is not alone in offering
the addition of the new criteria, there alternative or elaborated labels for chil-
is still just one basic symptom: a lack of dren with selective mutism. For ex-
speech. These children tend to learn ample, Golwyn and Weinstock (1990)
normally and to interact with their and Black and Uhde (1992) reported it
peers, albeit nonverbally (Lumb & to be a symptom of social phobia.
Wolff, 1988). This article will review Crumley (1990) also noted this as a
information regarding possible causes possibility in his discussion of a subject
and treatments for selective mutism. who described panic attacks and a fear
(For more extensive reviews of the lit- of saying something that would be em-
erature, readers are referred to Cline & barrassing as being associated with his
Baldwin, 1994, and Kratochwill, 1981.) childhood mutism.
Subgroups
ASSOCIATED DISORDERS, Various attempts to identify and label
SUBGROUPS, AND CAUSATIVE specific subgroups of children with se-
FACTORS lective mutism have been made
(Wright, Miller, Cook, & Littman,
1985). One such classification system,
Associated Disorders developed by Hayden (1980), provides
There is disagreement regarding whether a detailed list of subgroup characteris-
selective mutism is a separate problem tics, along with probable causes for the
or a symptom of some other disorder mutism found in each group. His cat-
(Krolian, 1988). Lesser-Katz (1986) egories appear to be the most specific
believes a single symptom—in this case, and are inclusive of those subtypes iden-
silence—does not present itself in iso- tified by others (Wright et al, 1985).
lation. Instead, she views selective Hayden (1980) studied 68 children
mutism as a symptom of stranger reac- with selective mutism from the U.S.
tion. In this condition, children react West and Midwest. The children's ages
BEHAVIORAL DISORDERS, APRIL 1995, VOL. 3, NO. 2, PAGES 100-107
 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 passive-
aggressive.
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, non-
verbal, 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 dis-
playing this subtype had a fear of hear-
ing their own voices, displayed ritualistic
behavior around speech, and were mo-
tivated to regain speech. They also were
more likely than any of the other sub-
types 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 chil-
dren in this group also displayed symp-
toms of depression.
Passive-aggressive mutism, the fourth
category, "was characterized by using
silence as a weapon, expressing clearly—
albeit silently—hostility by defiant re-
fusal to speak" (Hayden, 1980, p. 126).
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These children also displayed frequent
and sometimes violent antisocial behav-
ior. 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 manipu-
late the world in some way.
The general characteristics of all
these subtypes included physical ten-
sion, 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 with-
drawal.
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, pathologi-
cal 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 selec-
tive 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 psy-
chosexual development (Silverman
& Powers, as cited in Colligan,
Colligan, & Dilliard, 1977);
3. Fixation on or regression to behav-
ior that is normal in younger chil-
dren who have stranger anxiety
(Lesser-Katz, 1986);
4- Displaced hostility (Elson, Pearson,
Jones, & Schumacher, 1965);
5. An attempt to protect a precarious
EMOTIONAL AND BEHAVIORAL
self-image (Halpern, Hammond, &
Cohen, 1971);
6. A child's need to control aggres-
sive and destructive fantasies
(Halpern et al., 1971; Wergeland,
1980);
7. An aspect of social phobia (Black
& Uhde, 1992; Crumley, 1990);
8. A failure of socialization (Younger-
man, 1979);
9. A failure of normal language de-
velopment between mother and
child during the first 2 years of life
(Krolian, 1988); and
10. Impoverished maternal language
(Krolian, 1988).
Others, however, have found no con-
clusive cause for this disorder (Kolvin
& Fundudis, 1981; Golwyn & We in-
stock, 1990). It therefore appears that
there may be many different causes for
selective mutism, and more than one
factor might be involved in the devel-
opment of this disorder in any particu-
lar child.
As Tancer (1992) pointed out, stud-
ies and discussions of selective mutism
include a heterogeneous group of chil-
dren. The fact that this disorder is char-
acterized 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 regard-
ing causes and subtypes or the possibil-
ity 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 be-
fore 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).
DISORDERS, APRIL 1995, VOL. 3, NO. 2 JQ J
 According to the DSM-IV, adults Labbe and Williamson (1984) also therapy, and occupational therapy last-
may not notice the mutism until the discussed the need to assess a child'sing from 8 months to 4 years. However,
children enter school. However, the verbal behavior in varied situations.the mutism in the cases where these
classroom expectation for speech, and They indicated five possible outcomestherapies were used did not disappear
these children's failure to comply, is from such an assessment: a child who in all instances. Wergeland believes
not always enough to prompt a rapid psychoanalytical therapy with mute
referral. Referral ages span a range from 1. Speaks occasionally to most persons children can be demanding and lengthy,
5 years to 11 years (Hayden, 1980; in most test environments; as well as exasperating and intolerable
Krohn et al., 1992; Wergeland, 1980; 2. Speaks to only one or a few persons for some therapists. Such reactions most
Wright et al., 1985), and an examina- in most test environments; likely result because the mute child does
tion of the literature indicates that some 3. Speaks to most persons in only one not participate in the basic component
children have been mute during 8 years test environment; of most psychodynamic approaches:
of school before a referral occurs. 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
test environment. use of that silence and the accompany-
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 inter- Krolian (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 psycho-
Baldwin and Cline (1991) offered counseling; and behavior modification dynamic perspective and although psy-
an 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 devel- It 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 out-
believe 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 re-
also 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 com-
ing 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 depict-
102 JOURNAL OF EMOTIONAL AND BEHAVIORAL DISORDERS, APRIL 1995, VOL. 3, NO. 2

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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 occur-
rence in psychotherapy approaches
(Lumb & Wolff, 1988), it is not always
present (Afnan & Carr, 1989).
Wergeland (1980) noted that chil-
dren treated by psychoanalysis at the
University of Oslo showed improvement
when a change was made in the envi-
ronment 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 be-
gun to speak normally without the dras-
tic 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 neces-
sary 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, fam-
ily therapy involved only the parents
and was aimed toward the development
and supported implementation of a
stimulus fading program at school in-
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volving the mother, coupled with rein- Contingency Management* Albert-
forcement at home. Stewart (1986) used a token economy
system in an outpatient clinic to im-
D r u g Therapy prove the oral language skills of a 13-
year-old boy who had been selectively
In a pharmacological approach to se-
mute at school for 8 years. For 11 ses-
lective mutism, Golwyn and Weinstock
sions, the boy read into a tape recorder
(1990) successfully treated a 7-year-old
and was rewarded for the volume and
girl with the antidepressant phenelzine.
clarity of his speaking. After these ses-
These authors view selective mutism as
sions, with encouragement from his
being similar to anxiety disorders in
teacher and classmates, he was able to
adults, and they noted that phenelzine
increase the quantity of his speech in
has been successful in making adults
school. It should be noted, however,
with social phobia talkative. T h e treat-
that he was not totally mute, but in-
ment lasted 24 weeks; 5 months after it
stead engaged in occasional whispering
ended, the mutism had not returned.
and monosyllabic utterances.
Black and Uhde (1992), who view
Calhoun and Koenig (1973) reported
selective mutism as a symptom of social
success with the use of class-wide re-
phobia, successfully treated a 12-year-
wards contingent upon verbal exchanges
old girl with the drug fluoxetine. Previ-
between teachers and students. The stu-
ous p s y c h o t h e r a p y and b e h a v i o r a l
dents in this case were eight children
interventions had been unsuccessful
in Grades K to 3 from bilingual, non-
with this student. The girl, who had
W h i t e backgrounds. These children
not spoken at school before the initia-
were discouraged from using their pri-
tion of drug therapy, began to talk to
mary language at school and were re-
peers and adults, participated in oral
ferred because of "grossly deficient or
presentations, and volunteered answers.
absent verbal behavior directed to adults
In one of the few studies of selective
in the classroom" (p. 700).
mutism to make use of a control group,
Because speech was not completely
Black and Uhde (1994) used either
absent in these two just cited studies,
fluoxetine or a placebo with 15 selec-
they perhaps would be more appropri-
tively mute children for 12 weeks. Dif-
ately classified in terms of reluctant
ferences between the groups were mostly
speech, which was described by Wil-
nonsignificant; however, parents did rate
liamson, Sewell, Sanders, and Haney
those subjects receiving fluoxetine as
(1977). Although these studies used
showing significantly more improve-
contingency management as the sole
ment in their mutism. Teacher and cli-
behavioral technique, it is more fre-
nician ratings were nonsignificant. In
quently combined with other behavior
addition, "treatment effects were mod-
modification methods.
est and most of the subjects were still
significantly impaired at the end of the
Stimulus Fading* In a case of stimu-
study period" (p. 1005). There were
lus fading, Conrad, Delk, and Williams
indications that a longer treatment pe-
(1974) reported on an 11-year-old girl
riod may produce more beneficial re-
who had not spoken at school for 5
sults.
years. Their program required 12 ses-
sions and at the beginning involved
Behavior Modification
tangible reinforcers. T h e first session
The most commonly used treatment for took place in the child's home with her
selective mutism is some form of be- mother and a mental health worker
havior modification, such as contin- present. In this session, the girl was re-
gency management, stimulus fading, warded when she orally responded to
shaping, desensitization, extinction, arithmetic flash cards presented by the
aversion, and various combinations of mental health worker. Sessions 2 and 3
these approaches. Self-modeling has also were similar except the mother was not
been combined with behavioral ap- present and the reinforcement sched-
proaches. ule changed from continuous to fixed
EMOTIONAL AND BEHAVIORAL DISORDERS, APRIL 1995, VOL. 3, NO. 2 JQ3
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 responsibil-
ity of presenting the stimuli. At this
time, a point system replaced the tan-
gible 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 gen-
eral education classroom. This intro-
duction 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 inter-
vention in Rasbury's (1974) study of an
11-year-old girl who had been selec-
tively 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 re-
quired her to read orally sentences
JOURNAL OF EMOTIONAL AND
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printed on index cards while she trav- was established in the clinic setting,
eled to school. The cards described the sessions moved to the school. Vid-
school events and if she read them all eotaping of each session occurred while
(and later read them in a normal tone the stimulus fading procedures were tak-
of voice), she was allowed to choose ing place in the clinic. Before the move
one of the activities in which to par- to the next step in the stimulus fading
ticipate that day. This procedure took procedure, the girl watched her success-
the girl through a hierarchy of 15 steps ful verbalizations from the previous
that involved getting her to speak both sessions. By making use of the self-
to other people and the closer she got modeling procedure in this way,
to school. Holmbeck and Lavigne eliminated the
Another desensitization study (Reid need for videotape editing. Once the
et al., 1967) took place in 1 day at a therapy moved to the school, contin-
clinic. When prompted every 30 sec- gency management was added and re-
onds by her mother, a 6-year-old girl wards were provided for success in
had to ask for food while a stranger progressively more difficult verbal tasks.
moved progressively closer to them. The
next step involved the stranger telling Extinction and Aversion. Some
the mother to ask the girl to request studies have relied on extinction
food and then moved on to having the (Dmitriev & Hawkins, 1974) or aver-
stranger ask the girl directly if she sion (Van Der Kooy & Webster, 1975)
wanted food. Gradually more adults and to eliminate mutism in school-age chil-
two children were introduced under dren; however, the use of these inter-
similar circumstances. Follow-up ses- ventions raises the issue of professional
sions showed improved speech. 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.
and social learning through self- Not all such approaches may be abu-
modeling. Pigott and Gonzales (1987) sive. Watson and Kramer (1992) used a
videotaped a child answering questions shaping program that combined posi-
in 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 com-
and 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 extinc-
teacher-child interactions in the class- tion or aversion, and professionals
room. The children viewed the videos should not make either of these tech-
daily and were reinforced each time niques their primary intervention.
verbal interactions occurred on the tape. Although lacking the specificity of
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 chil-
for 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 dig-
gradually added to situations where the nity. No matter what treatment ap-
girl and her mother were talking. After proach professionals choose, such a
the girl was able to converse with the concern must be maintained and inte-
therapist, a classmate was brought to grated into all aspects of the therapy.
the clinic, followed in subsequent ses- Not all approaches have this compo-
sions by another class member and the nent, however. Examples include the
teacher. After speech with the teacher previously cited studies by Dmitriev and
BEHAVIORAL DISORDERS, APRIL 1995, VOL. 3, NO. 2
Hawkins (1974) and Van Der Kooy and
Webster (1975). Another example is
the Hawthorn Center approach de-
scribed 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 confronta-
tion 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 gen-
eralization 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 sponta-
neous speech in the presence of non-
family 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 prob-
lem have been disappointing for the
circumstances under which they mea-
sured 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 prac-
tical level. As noted previously, their
approach involved an initial determi-
nation 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 envi-
JOURNAL OF
Downloaded from ebx.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on January 26, 2015
ronmental elements. Although this ap-
proach acknowledges the importance of
environmental conditions in producing
verbal behavior, professionals should
also examine the conditions influenc-
ing the types and degree of nonverbal
communication in which the child en-
gages (Frenchette, 1989). This may as-
sist 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 re-
search. The resulting answers could have
a major impact on the assessment pro-
cess 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 par-
ticular causes for differing subtypes and
the best intervention(s) for specific sub-
types, 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 sur-
face level. If the mutism seen in this
disorder is caused by a more severe prob-
lem, such as abuse, or if it is a sign of a
more far-reaching disorder, such as so-
cial phobia, then treatments that tar-
get 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 se-
vere problem.
Perhaps another reason there are
questions about the nature of selective
mutism is due to a lack of good infor-
mation regarding generalization and
long-term prognosis. Most reports con-
cern only the mutism and do not ex-
plore other social and academic
EMOTIONAL AND 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 situ-
ations 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 adjust-
ment, academically or socially" (p. 200).
Wergeland (1980) also noted mixed
results regarding general adjustment up
to 16 years after treatment. These re-
sults 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 be-
havior.
Hayden's (1980) subtypes also indi-
cate that there is more involved with
these children than simple silence and
that there is a need for more than be-
havioral interventions. Family therapy
and play therapy seem to be logical al-
ternatives or additions—family therapy
due to the presence of family problems
in many researcher's reports and play
therapy because it provides young chil-
dren with the means of communicating
nonverbally.
No matter what intervention is cho-
sen, teachers and therapists need to be
aware that any treatment plan may take
a long time to be effective. Cunning-
ham, 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 in-
terventions 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 etiolo-
gies, careful diagnosis and therapy selec-
DISORDERS, APRIL 1995, VOL. 3, NO. 2 ^05
tion are important. These processes
would be aided by additional research
that explores whether there are differ-
ences between persistent and transient
mutism, as Tancer (1992) has recom-
mended, and by research that compares
the effectiveness of the various treat-
ments. Kratochwill et al. (1979) offered
a good critique of research methodolo-
gies found in the selective mutism lit-
erature. In addition to their suggestions
on how to improve single-subject re-
search, 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 Col-
lege in Vermont. He is an educational diag-
nostician currently pursuing a doctorate in
educational psychology at American Inter-
national 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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295.
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MOTIONAL AND BEHAVIORAL DISORDERS,