Silent suffering: understanding and treating children with selective mutism.

Children with selective mutism (SM) restrict speech in some social environments, often resulting in substantial academic and social impairment. Although SM is considered rare, one or more children with SM can be found in most elementary schools. Assessment is performed to confirm the diagnosis, rule out psychological and medical factors that may account for the mutism, ascertain comorbid and exacerbating conditions needing treatment, and develop an intervention plan. Interventions are often multidisciplinary and focus on decreasing anxiety, increasing social speech and ameliorating SM-related impairment. Research is limited, but symptomatic improvement has been demonstrated with behavioral interventions and multimodal treatments that include school and family participation, as well as behavioral methods. Selective serotonin-reuptake inhibitors, especially fluoxetine, have also been found to be efficacious and merit consideration in severe cases. Persistence of some SM or anxiety symptoms despite treatment is common. Further development of treatments targeting specific etiological factors, comparative treatment studies and determination of optimal involvement of families and schools in treatment are needed to improve outcomes for children with SM.