Selective Mutism: Symptoms, Causes, Treatment, and Tips for Parents

Selective Mutism: Symptoms, Causes, Treatment, and Tips for Parents


金宝博亚洲投注选择性缄默症(SM) wh的焦虑症ich children do not speak in school, extracurricular or community activities, sports, etc., despite speaking at home or in other settings. Children with SM have the ability to speak and are often described by immediate family members as ‘chatty’ or ‘talkative’ when observed at home and in other select environments. Despite speaking freely at home, children with SM appear to ‘freeze’ and remain mostly or completely silent in social situations depending on the person, place, and situation or activity. Even subtle changes around them or shifts outside of their comfort zone can lead to drastic changes in (non)speaking. A child with SM may talk loudly and enthusiastically to a parent at home, in the grocery store aisle, and at a restaurant, but may immediately become, and remain, silent when a neighbor visits the home, an adult or peer walks in the same grocery aisle, or a waiter approaches the table to take an order. As known and deeply felt by families who are coping with SM, this pattern of reluctance in speaking greatly impacts the child’s fundamental ability to convey their needs and to engage fully at school, with friends, during afterschool activities, and in their neighborhood and community.

对于儿童体验一系列口语行为并更围绕新儿童和成人保留,这可能是健康和适应性的,特别是远离护理人员。即使是最大社会和外向的孩子也可以有沉默的时刻或说话不愿意对日常运作的影响而没有持久的影响。注意,发育适当的沉默是短暂的和临时的和这些人当期望发言时说话(例如,在课堂上呼吁或者如果他们想玩的话)。因此,我们进一步区分儿童与那些没有SM的人,因为那些有一个人consistentrefusal to speak in specific social situations in which there is an expectation for speaking (e.g., at school), despite speaking in other situations (e.g., at home with family members), and the silence or reluctance to speak has a负面影响在孩子的日常生活.



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Parents, caregivers, teachers, and mental health or medical providers unfamiliar with SM may misperceive social silence as ‘shyness’ or a temporary phase that the child ‘will outgrow.’ As a general guideline, shyness represents an initial experience of reticence that is most likely to occur in new or unfamiliar settings or before an adequate ‘warm-up’ period. A ‘shy’ child without SM may appear quiet during the first half of a friend’s birthday party when unfamiliar peers are present, within the first few weeks of a new school year, or when asked by a teacher to present to a small group or whole class without any notice or time to prepare. By comparison, a child with SM may continue to remain silent despite extensive warm-up periods, including after multiple playdates with a classmate, years in school with the same peers, or when asked by a friendly peer or adult about their name, age, or favorite interests. SM often impacts a child’s ability to get help, request to use the restroom, or tell others if they are hurt, lost, or in pain. See the table below for side-by-side comparisons.


Naturally, adults or children may also mistake selective silence in children with SM as ‘rudeness’ or deliberate attempts to defy others. It is important to recognize that children with SM suffer from anxiety and their silence is most often ‘rooted’ in worry associated with social evaluation or judgment, fear of making social mistakes, and uncertainty about one’s ability to be liked and accepted. Since the difficulties with verbal communication are consistent for individuals with SM, over time they can be labeled as the ‘one who does not speak.’ Further, children with this condition who are not appropriately identified and treated are at risk for the development of social anxiety disorder and other mental health disorders, as well as continuing to suffer from SM as adolescents and adults. This trajectory often leaves individuals and families feeling stuck in a pattern of social silence that greatly influences social, emotional, academic, and occupational health.

Read this important article about SM in Teens and Adults.

症状and Common Traits

SM is best understood as an anxiety-based condition resulting in limited verbal communication among individuals, particularly children, who are otherwise verbal in the home or select environments. To diagnose SM, the symptoms of persistent silence in social settings must be present for a least one month, or longer than six months, if it is the first year attending school. The failure to speak cannot be due to a lack of knowledge of, or comfort with, the spoken language required in the social situation. SM is also not an appropriate diagnosis when the failure to speak is due to a primary language or communication disorder or other disorders, such as an autism spectrum disorder. These conditions should be ruled out as needed to make appropriate diagnoses and related treatment recommendations.


Within the umbrella of SM, children with this disorder may vary in terms of how they use their voice and body language to communicate with others, ranging from minimal to frequent and appropriate use of verbal and nonverbal behaviors.

Beginning with the most limited communication style, some children with SM may限制几乎所有的口头和非语言通信在社交场景中。这些儿童可能呈现紧密闭合的嘴巴,最小的眼睛接触,并具有无表情脸。这种有限的口头和非语言提示的模式可以让别人不确定这些孩子在思考和感受,最重要的是,他们是否有任何未满足的情感,教育或医疗需求。

有些孩子可以仅使用非语言通信进行沟通such as nodding, smiling, pointing, writing, signing, or miming. These children may be able to get many of their needs met by nodding to yes/no questions, pointing to answers in a book, and writing to express their ideas; however, prolonged or sole use of nonverbal communication can increase the reliance on nonverbal measures and decrease opportunities for a child to practice, and gain comfort with, speaking.

Other children make听起来和噪音(例如,咕噜声,嘟,动物声音)和话语(例如,嗯,uh-huh)而不是可理解的词语。

Many children with SM will耳语或使用改变声音,如使用较深或较高音调的声音、机器人或动物的声音等。耳语或使用改变过的声音通常会对他们的声带造成压力,比他们典型的声音需要更多的努力,但使用时感觉不那么暴露和焦虑。

Some children speak清晰可听to certain individuals, and in certain places outside of the home, despite the lack of speech in others.


Treatments for selective mutism include psychological/behavioral or pharmacological treatments. However, psychological/behavioral treatments are the first line treatments for selective mutism. Children who do not respond to these treatments might benefit from pharmacological interventions.

Psychological/Behavioral Treatment


SM的黄金标准干预是行为治疗(WONG,2010)。行为治疗具有最大的SM支持的研究基础,因此通常是第一个推荐的治疗选项。行为疗法旨在减少焦虑和避免,增加言论和其他言语,并减少对抗或消极注意力(Cohan,Price&Stein,2006)。行为技术包括塑造,刺激衰落,行为露出和应急管理(Bergman,2013; Cohan等,2006)。

  • Shaping发生在最终目标的逐步步骤中。父母经常使用塑造来实现骑自行车的目标。塑造步骤可能包括赞美戴着自行车头盔的儿童,站在自行车附近,坐在座位上,拿着把手,骑在训练轮上,父母骑自行车的同时没有训练轮,最终独立骑行。For children with SM, there can be a huge jump between not speaking and speaking, with steps including relaxed mouth, blowing air through mouth, sounds, speaking in an audible voice volume, answering forced choice questions (‘is this blue or red?’), and using full sentences.
  • 刺激褪色涉及一次改变一个变量,以便将演讲从一个人,地点或情况转移到新的通信合作伙伴,地方或活动期间儿童当前可能不会发言的活动。例如,淡入淡化可能涉及以下顺序:儿童在单独在课堂上播放游戏时给父母说话,教师进入房间,慢慢地走向孩子和家长之间的戏剧(坐在房间里;坐在房间里距离;近距离),参加比赛(增加目光接触并观察游戏),口头参与互动(对游戏的评论,直接发言,要求孩子强制选择问题),父母慢慢褪色走出游戏,然后是房间。
  • 衰退features essential components from Parent-Child Interaction Therapy (PCIT), which was originally developed to treat childhood disruptive behaviors, has been modified for children with SM (PCIT-SM). PCIT-SM focuses on teaching communication skills to parents, problem solving, consistency and follow-through, and providing positive attention/praise to desired child behaviors. PCIT-SM involves live parent coaching from a trained clinician with the use of an earpiece while the therapist observes the parent-child interaction in a different room. Two phases comprise PCIT-SM: 1) Child-Directed Interactions (CDI), and 2) verbal directed interactions (VDI).
  • CDIcan be thought of as a warm-up period in which the parent enthusiastically follows the child as they play, without providing any guidance, commands, criticism, or prompts to speak.VDI涉及计划使用问题,并以后,命令。父母受过VDI培训,赞扬言语行为,并提供有效的提示,增加言语(即,强制选择问题,开放式问题),并劝阻非语言行为。餐厅的强迫选择问题的一个例子可能是“你想要午餐披萨或意大利面吗?”
  • Exposure therapy利用恐惧层次结构或梯子,“将”暴露“一个人以SM曝留到需要非口头沟通或言语的各种情况,随着整个治疗的难度水平增加。然后,儿童根据提供者,父母,儿童和可能的,学校团队成员,合作的行为计划,该儿童是积极奖励的。整个治疗的关键目标和重点是尽可能多的个人,设置和情况拓展言语和社会收益(Raggi,Samson,Loffredo,Felton&Berghorst,2018)。
  • 应急管理使用奖励系统来庆祝勇敢的行为并限制对问题行为的关注。




Although selective serotonin reuptake inhibitors (SSRIs; e.g., Prozac, Zoloft) are common medical treatments for anxiety and mood disorders, there is limited research in the use of these medications for selective mutism; however, the limited data have shown promising results, especially for children who do not respond to psychological/behavioral interventions (Carlson, Mitchell, & Segool, 2008).

The role of pharmacological methods in the treatment of SM is largely unknown as there are few large-scale experimental pharmacology trials. Most of the research available on medication and SM is based on small samples; however, a recent review pointed to Selective Serotonin Reuptake Inhibitors (SSRIs) as the most promising medication treatment option for children with SM (Carlson, Mitchell & Segool, 2008). Generally speaking, medication is used as a secondary means of SM treatment if children are not responsive to behavioral therapy. In addition to poor behavioral therapy response, medication may also be indicated when children have severe SM impairment, comorbidities, and/or a strong family history of SM or anxiety. When medication is utilized, the goal is short-term use in conjunction with behavioral intervention. Currently, there are no medications with FDA approval for the specific treatment of SM. It is important to take note of potential side effects when considering utilizing medication in the treatment of childhood SM.


SM affects approximately 1% of the general population (APA, 2013; Bergman, 2012). Despite being considered a rare condition, these prevalence rates are similar to, or greater than, those documented for autism spectrum disorders. SM is an early onset disorder and commonly begins in children approximately ages 2.5 - 4 years old. Children with SM are often identified at ages 5-6 years, reflecting a 1-3 year gap between the onset of symptoms and identification (Kotrba, 2015). Formal assessment and treatment for SM typically occur at ages 6.5-9 years, which coincides with 4 years in school (Kotrba, 2015). These delays can lead to a more ingrained set of rules for (non)speaking, and place children at risk for being labeled as the ‘one who does not speak,’ as well as for a continued diagnosis of SM in adolescence and adulthood.




SM is also found to be highly comorbid with various communication disorders (APA, 2013). In one study, 32% of children had receptive language difficulties and 66% had deficiencies in expressive language (Klein, Armstrong, Shipon-Blum, 2012). While it is certainly possible for a child to have a communication disorder and SM, an SM diagnosis is not warranted if the lack of speech is directly caused by the communication disorder. There are situations in which these disorders can both be present: for example, if a child does not speak in front of others because of worries about how their communication disorder affects their speech (e.g., “I sound funny”), then a diagnosis of SM may be warranted.

Causes and Risk Factors

如同大多数心理障碍,没有“one cause” for SM. In fact, SM may be due to a combination of temperamental, genetic, environmental, and neurodevelopmental factors (Muris & Ollendick, 2015). Children with SM are often described as being behaviorally inhibited since infancy (Gensthaler et al., 2016). Broadly, anxiety has a strong genetic basis and tends to run in families, with heritability ranging from 25-50% (Czaijkowski, Roysamb, Reichborn-Kjennerud & Tambs, 2010). Among individuals with SM, 70% have a 1英石学位相对a history of social anxiety disorder, and 37% have a 1英石学位相对a history of SM (Chavira, Shipon-Blum, Hitchcock, Cohan, & Stein, 2007). For children with SM, social interactions or settings where speech is expected may trigger the fight-flight-freeze response typical of all anxiety disorders. Further, these reactions or behaviors may then be reinforced when children “escape” the fear-inducing situation by not speaking. This cycle of avoiding speech and subsequent reductions of anxiety may be viewed as an “effective” avoidance technique (Young, Bunnell & Beidel, 2012). Well-intentioned parents, siblings, and others will often ‘speak for the child’ or remove speaking demands, accidentally reinforcing the child’s silence. See the behavioral conceptualization graphic below.


研究还指出,声音转换和处理的可能差异与SM有关(Henkin&Bar Haim,2015;穆里斯和奥伦迪克,2015)。从本质上讲,大脑和耳朵的某些部分可能会导致SM儿童听到自己的声音和其他声音,这与正常发育的儿童不同。SM儿童的一些其他风险因素可能包括家庭功能障碍、创伤、学校环境、欺凌、移民身份和社会/发展延迟(Muris&Ollendick,2015),但同样需要注意的是,这些风险因素都不一定是SM发展的“原因”。

Cultural Differences

迄今为止,迄今为止,文化差异尚未在SM的儿童中记录。然而,一个重要的文化考虑是区分SM与非语言沟通期间(或“沉默时期”)在学习主办国的语言时的移民儿童经验。在学习第二语言时,孩子通常会通过四个熟练的阶段移动:1)预期在第二语言中发言时持续沉默,2)在第二语言中练习和重复单词;3)在第二语言持续下悄悄地练习单词和短语的“沉默时期”,从数周到六个月;4)用第二语言“公开”(例如,Samway和Mckeon,2002)。由于担心他们不会和其他人担心,双语移民儿童通常不会进展过去三阶段,导致长期沉默。说话不情愿的症状可能更明显和在第二语言中持久;然而,双语移民儿童将持续在他们预期发言的情况下持续发言,通常会影响两种语言。这种无法发言是对孩子的语言能力和熟练程度(Toppelberg&Collins,2010; Toppelberg,Tabors,Coggins,Lum,&Burger,2005)的不成比例。



如果可能的话,父母应该让孩子去the new classroom before the beginning of the school year. The parent should encourage verbal behavior at school so that the child begins to feel comfortable in his/her new environment without the pressure of having other children or adults around. Similarly, have the child meet his/her teacher before the first day of school. The goal is not necessarily to have the child speak to the teacher but should be an opportunity for the child to start feeling comfortable with a new adult. If the child does spontaneously speak, the teacher or the parent should immediately praise the verbal behavior in a simple manner (‘thanks for telling me’) and quickly redirect back to the topic or activity. It is critical that there be ongoing communication between parents and teachers to assess progress and quickly address barriers to goals. If the child is joining a new after school activity, have the child meet the coach/instructor ahead of time.

Parents can share the following tips with adults and other people the child does not speak to:

  • Always praise口头行为和be specific!“Thanks for asking to use the restroom,” or “I liked how you asked Cindy to borrow a crayon.”
  • Wait 5-10 seconds.Do not immediately jump in to respond. Give the child an opportunity to respond. Show that you are comfortable with a few seconds of silence.
  • 使用强制选择问题(‘is this red, blue, or something else?’) instead of yes/no questions (‘is this red?’) or open-ended questions (‘what color is this?’). Children with SM are likely to respond to yes/no questions by nodding or shaking their heads and freeze in response to open-ended questions.


  • Have you received direct training in evidence-based treatment (i.e., cognitive-behavioral therapy (CBT) and behavioral approaches) for children with SM?
    • Advanced training may include completion of the Selective Mutism Training Institute (SMTI) through the Selective Mutism Association, or direct training and/or supervision by a known expert in SM (e.g., Steven Kurtz, Child Mind Institute).寻找使用CBT和行为方法对待儿童焦虑的提供者也有所帮助,并且熟悉SM,因为SM被认为是一种焦虑症。如果您没有接受过SM循证治疗方面的直接培训,您是否愿意在我的孩子接受治疗期间寻求和/或参与培训师或SMTI毕业生或其他已知SM专家的持续咨询?The Selective Mutism Association website lists providers who are members of the Selective Mutism Association and who self-identify as treating providers of SM. These providers may be qualified to provide consultation to a child’s active treatment provider who is skilled in CBT and behavioral techniques for anxiety disorders, but is less familiar with SM.
  • 你对待有多少名SM的孩子,结果是什么?
    • 请记住,只有1个在5位的成年人中听过SM,甚至更少的心理健康提供者都专注于这一领域。然而,由于SM是一种童年焦虑的形式,因此可以帮助寻找使用CBT或行为技术治疗儿童焦虑的提供者。SM的治疗通常是短期,持续数月而不是岁月。熟练的提供商通常会报告每个会议在待遇的前几届会议上,每个会议都针对演讲行为和一个孩子以SM语言。
  • 你用什么行为技巧来定位演讲?
    • SM处理中最有效的行为技术包括衰落,成型和暴露治疗(参见本文的治疗部分)。
  • 父母、照顾者和兄弟姐妹在治疗中扮演什么角色?
    • Naturally, parents and siblings want to help, but sometimes what feels helpful in the moment can accidentally lead to more anxiety in the long run. For example, a well-meaning parent or sibling who sees a child struggle to answer a question posed by a store clerk may answer for that child. While this may break an awkward silence, the child will miss out on the opportunity to be brave. Parent training typically includes education regarding the brave cycle and avoidance cycle, ways to help without falling into common pitfalls, how to reduce accommodating behaviors (i.e., those that enable avoidance/silence), and specific techniques to fade-in new communication partners and in new settings.
  • 你如何与学校合作并在学校内部促进演讲?
    • 治疗计划可以包括在学校、教练组中直接观察孩子,以及在学校进行淡入或塑造课程,以增加与同龄人和教职员工的交流,以及在小组和全班环境中(请参阅本文的“家长和教师提示”一节)。
  • 您如何帮助SM的儿童增加他们在治疗之外的演讲,包括日常活动以及他们想要的事情或需要做的事情?
    • 接触可以在社区中进行,也可以在一些公共区域进行,在这些区域,SM儿童通常需要额外的支持,比如在餐厅点餐,请同伴在公园玩耍,告诉图书管理员孩子在找什么类型的书。




  • 金宝博亚洲投注选择性互动:Aimee Kotrba的治疗师,教育工作者和父母的评估和干预指南
  • Overcoming Selective Mutism: A Parent’s Field Guide by Aimee Kotrba and Shari Saffer
  • The Selective Mutism Resource Manual by Maggie Johnson
  • Helping Your Child with Selective Mutism: Practical Steps to Overcome a Fear of Speaking by Angela E. McHolm, Charles E. Cunningham, and Melanie K. Vanier
  • 帮助选择性缄默症儿童及其父母:克里斯托弗·卡金宝博亚洲投注尼的校本专业人士指南
  • 暴露治疗儿童和青少年焦虑的疗法是Veronica Raggi,Jessica Samson,Julia Felton,Heather Loffredo和Lisa Berghorst的综合指南
  • 了解凯蒂伊莉莎希彭布鲁姆
  • 玛雅张文昌的声音
  • 查理的玛丽安莫尔诺尔的选择


  • Mindfulness and Mediation: Headspace, Calm
  • 深呼吸:呼吸2Relax
  • 需要演讲的互动游戏:魔法精灵,尖叫的小鸡



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