Selective Mutism: Causes and Interventions

ALAN M. HULTQUIST

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.

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.

These five criteria are a substantial change over those listed in the DSM-III-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 lit-erature, readers are referred to Cline & Baldwin, 1994, and Kratochwill, 1981.)

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 symptom—in this case, silence—does not present itself in iso-lation. Instead, she views selective mutism as a symptom of stranger reac-tion. In this condition, children react

to unfamiliar situations or people by withdrawing.

Lesser-Katz is not alone in offering alternative or elaborated labels for chil-dren with selective mutism. For ex-ample, 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 em-barrassing as being associated with his childhood mutism.

Subgroups

Various attempts to identify and label specific subgroups of children with se-lective mutism have been made (Wright, Miller, Cook, & Littman, 1985). One such classification system, developed by Hayden (1980), provides a detailed list of subgroup characteris-tics, along with probable causes for the mutism found in each group. His cat-egories appear to be the most specific and are inclusive of those subtypes iden-tified 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 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).

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

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).

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According 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 examina-tion of the literature indicates that some children have been mute during 8 years of school before a referral occurs.

ASSESSMENT AND TREATMENT

Assessment

Once a child is referred, an assessment needs to be conducted and the ques-tion of what treatment(s) to initiate needs to be answered. The traditional psychoeducational assessment process (e.g., cognitive, emotional and behav-ioral, and academic performance) may not always be possible with a child who is selectively mute due to the lack of expressive language. However, such approaches may be necessary to rule out possible language-based disorders or other diagnoses.

Baldwin and Cline (1991) offered an extensive discussion of assessment in selective mutism. They pointed to the need to explore family and devel-opmental histories. In addition, they believe that it is necessary to examine the current situation in terms of how much and to whom the child speaks in particular situations and to explore three possible themes: the meaning of com-munication for the child, the way si-lence might be helping the child to control certain situations, and what role, if any, anxiety plays. Baldwin and Cline also discussed the need to assess: (a) the environment to discover any persons or factors that might be help-ing maintain the mutism, (b) the non-verbal communications that are engaged in by the child or that elicit a response from the child when used by others, and (c) family members for factors other than the mutism that might be of pri-mary concern to them.

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

1. Speaks occasionally to most persons in most test environments;

2. Speaks to only one or a few persons in most test environments;

3. Speaks to most persons in only one test environment;

4. Speaks to only one or a few persons in only one test environment; or

5. Does not speak to anyone in any test environment.

Based on the outcome of the behav-ioral assessment, Labbe and Williamson suggested a specific series of behavioral interventions.

In addition, with selective mutism there is perhaps an increased need to include outside sources (e.g., teachers, paraprofessionals, parents) in the assess-ment process. These outside sources are important not just for the assessment; they can also play a part in the inter-vention, depending on which type is chosen. Psychodynamic interventions; inpatient hospitalization; milieu, play, family, drug, or speech therapy; parent counseling; and behavior modification have all been reported (see the follow-ing discussion).

It is questionable as to whether in-tervention is necessary with all chil-dren who are selectively mute. Although Wergeland (1980) reported evidence of spontaneous remission (following a change of environment), Hayden (1980) noted the opposite. He stated that such remission is rare and is mostly restricted to mild instances of symbiotic mutism, and that children who have such a re-mission stop talking again later. These discrepancies raise the important issue of whether there are significant differ-ences between transient and persistent mutism that may hold important impli-cations for treatment (Tancer, 1992). This question has yet to be addressed.

Psychotherapy

Wergeland (1980) discussed inpatient and outpatient psychotherapy, milieu

therapy, and occupational therapy last-ing 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 children can be demanding and lengthy, as well as exasperating and intolerable for some therapists. Such reactions most likely result because the mute child does not participate in the basic component of most psychodynamic approaches: talking. However, even silence can be a form of communication (Krolian, 1988), and Youngerman (1979) made use of that silence and the accompany-ing nonverbal communication in his work with an adolescent boy who had been selectively mute for more than 10 years. Youngerman was successful both in reducing the therapeutic frustration he felt due to the boy's silence and in increasing the effectiveness of the therapy by switching to nonverbal in-teractions (e.g., facial expressions, mime, gestures, note writing), initially to the exclusion of speech.

Krolian (1988) described successful interventions with two children using a day hospital environment. However, although Krolian interpreted the children's behaviors from a psycho-dynamic perspective and although psy-chotherapy was one component of the treatments, other factors were involved, such as behavioral interventions, that most likely influenced the therapy out-come.

Some therapists have found play therapy to be effective. Weininger (1987) provided a detailed account of two case studies in which individual play therapy was effective in restoring speech to two first-grade girls; Barlow et al. (1986) used sibling play therapy with a 5-year-old girl. The latter re-searchers believe that play therapy of-fers a safe environment with no pressure for speech and allows the child to com-municate in a comfortable manner.

Pustrom and Speers (1964) combined play therapy for three children with selective mutism with therapy for the children's mothers. They noted that having the therapists interpret to the children the feelings they were depict-

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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 wi th select ive 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-

volving the mother, coupled with rein-forcement at home.

Drug Therapy

In a pharmacological approach to se-lective 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. The treat-ment 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-year-old girl with the drug fluoxetine. Previ-ous psychotherapy and behaviora l interventions had been unsuccessful with this student. The girl, who had not spoken at school before the initia-tion 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 selec-tively mute children for 12 weeks. Dif-ferences between the groups were mostly nonsignificant; however, parents did rate those subjects receiving fluoxetine as showing significantly more improve-ment in their mutism. Teacher and cli-nician ratings were nonsignificant. In addition, "treatment effects were mod-est 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 pe-riod may produce more beneficial re-sults.

Behavior Modification

The most commonly used treatment for selective mutism is some form of be-havior modification, such as contin-gency management, stimulus fading, shaping, desensitization, extinction, aversion, and various combinations of these approaches. Self-modeling has also been combined with behavioral ap-proaches.

Contingency Management* Albert-Stewart (1986) used a token economy system in an outpatient clinic to im-prove the oral language skills of a 13-year-old boy who had been selectively mute at school for 8 years. For 11 ses-sions, the boy read into a tape recorder and was rewarded for the volume and clarity of his speaking. After these ses-sions, 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 in-stead engaged in occasional whispering and monosyllabic utterances.

Calhoun and Koenig (1973) reported success with the use of class-wide re-wards contingent upon verbal exchanges between teachers and students. The stu-dents in this case were eight children in Grades K to 3 from bilingual, non-Whi te backgrounds. These children were discouraged from using their pri-mary language at school and were re-ferred 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 appropri-ately classified in terms of reluctant speech, which was described by Wil-liamson, Sewell, Sanders, and Haney (1977). Although these studies used contingency management as the sole behavioral technique, it is more fre-quently combined with other behavior modification methods.

Stimulus Fading* In a case of stimu-lus 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 ses-sions and at the beginning involved tangible reinforcers. The first session took place in the child's home with her mother and a mental health worker present. In this session, the girl was re-warded 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 sched-ule 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 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

printed on index cards while she trav-eled 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 par-ticipate 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 sec-onds 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 ses-sions showed improved speech.

Self-Modeling. Other successful treatments have involved behaviorism and social learning through self-modeling. Pigott and Gonzales (1987) videotaped a child answering questions in class while members of his family were off camera. Kehle, Owen, and Cressy (1990) taped a child answering questions directed at him by his mother and not answering the same questions posed by his teacher. In each case, the tapes were edited to show proper teacher-child interactions in the class-room. The children viewed the videos daily and were reinforced each time verbal interactions occurred on the tape.

Holmbeck and Lavigne (1992) com-bined stimulus fading and self-modeling in their work with a 6-year-old girl who had been silent at school for VJ2 years. The treatments began in a clinic and later moved to the school setting. In the clinic, a therapist was gradually added to situations where the girl and her mother were talking. After the girl was able to converse with the therapist, a classmate was brought to the clinic, followed in subsequent ses-sions by another class member and the teacher. After speech with the teacher

was established in the clinic setting, the sessions moved to the school. Vid-eotaping of each session occurred while the stimulus fading procedures were tak-ing place in the clinic. Before the move to the next step in the stimulus fading procedure, the girl watched her success-ful verbalizations from the previous sessions. By making use of the self-modeling procedure in this way, Holmbeck and Lavigne eliminated the need for videotape editing. Once the therapy moved to the school, contin-gency management was added and re-wards were provided for success in progressively more difficult verbal tasks.

Extinction and Aversion. Some studies have relied on extinction (Dmitriev & Hawkins, 1974) or aver-sion (Van Der Kooy & Webster, 1975) to eliminate mutism in school-age chil-dren; however, the use of these inter-ventions raises the issue of professional ethics. Because the techniques employed in these studies could be considered abusive, one must ask whether the end justifies the therapeutic means.

Not all such approaches may be abu-sive. Watson and Kramer (1992) used a shaping program that combined posi-tive reinforcement, mild aversives, and extinction in the school setting along with shaping, stimulus fading, and mild punishment at home and in the com-munity. It should be noted that careful consideration and constant monitoring need to accompany any use of extinc-tion or aversion, and professionals should not make either of these tech-niques their primary intervention.

Although lacking the specificity of the studies mentioned above, Friedman and Karagan's (1973) discussion deserves mention. These authors provided a list of seven guidelines for use with chil-dren who are selectively mute. These guidelines have as an unstated concern respect for the child and her or his dig-nity. No matter what treatment ap-proach professionals choose, such a concern must be maintained and inte-grated into all aspects of the therapy. Not all approaches have this compo-nent, however. Examples include the 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 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-

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

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-

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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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