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Pediatric Social Phobia and Selective Mutism Treatment & Management

  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD  more...
Updated: May 15, 2014

Medical Care

Prevention of complications of selective mutism (eg, school phobia, academic failure due to poor attendance) can be achieved by reinforcement by family, school, and physician of how important attending school is despite the child's desire to stay home and to avoid social events in order to reduce anxiety.[41, 42]

SSRIs are effective and superior to placebo, with efficacy rates of at least 65% in the treatment of patients with social phobia and the related disorder, selective mutism. The doses used in both children and adults are frequently much higher than those used for affective disorders.

Cognitive-behavioral therapy may be extremely helpful to improve the level of the child's autonomous functioning and should be performed by a clinician experienced in such therapy (eg, psychologist, psychiatrist, behavioral/developmental pediatrician). Cognitive approaches to both social phobia and selective mutism may be grouped into the several following types:

  • Contingency combined with stimulus fading: The desired behavior (ie, speaking out loud) is elicited with a stimulus or prompt; then, the prompt is gradually faded by decreasing the number of prompts, eventually to zero.
  • Behavior shaping combined with positive reinforcers: The child is rewarded every time she exhibits behavior that is closer and closer to the desired behavior (ie, speaking out loud). [43]
  • Positive reinforcers: Use of positive reinforcers such as a token economy or reward system for perfect attendance at school and special treats, such as a favorite book or movie for attending social events, may be successful. [44]
  • Aversive interventions: Forcing the child to speak out loud generally does not encourage the behavior to occur more often.
  • Systematic desensitization: The child or adolescent relearns how not to be upset or anxious when in a social situation. Instead of feeling uncomfortable in the situation, the child connects feelings of calm with the previously anxiety-provoking social situation. Instead of automatically reacting to the anxiety-provoking situation with autonomic nervous system activation, the behavioral response is reconditioned to that of relative autonomic nervous system deactivation.
  • Extinction: The undesired behavior (refusing to speak, hiding, refusing to go to school) is ignored, and the lack of attention to the behavior causes the behavior to cease. [43]
  • Modeling: The child or adolescent learns from a peer or adult therapist how to react in a calmer manner to the stressful situation. Research studies support the efficacy of using audio tapes or videotapes in treating selective mutism.
  • In vitro graded exposure: The child or adolescent imagines the stressful situation starting with the least stressful aspects, learning how to deal with these, and then following up with more stress-provoking aspects. This could include the use of scripted play therapy using real-life stressful situations with targeted responses for learning and incorporation.
  • In vivo exposure: The situation becomes less tension-provoking with repeated graded exposures as the situation becomes less new and more predictable. Careful real-life exposure (from less-threatening to more-threatening) to anxiety-provoking situations with postexposure discussion may be helpful, as actual experience of real-life situations determines whether resolution of the abnormal emotional response has taken place.
  • Social problem-solving: The child or adolescent is encouraged to view the social interaction that causes anxiety as a problem to be solved; this technique can be especially helpful when combined with the use of positive reinforcers and fading of prompts. [44]


See the list below:

  • To exclude hearing loss or other language disorder with selective mutism, obtain both a speech and language evaluation and an audiology evaluation.
  • If a more serious problem with interpersonal relatedness is suspected, the Childhood Autism Rating Scale (CARS) or other standardized tests may be administered by a licensed clinical psychologist to exclude childhood autism, pervasive developmental disorder, or reactive-attachment disorder. Autism and pervasive developmental disorders are behavioral diagnoses that can also be appropriately diagnosed by a pediatrician, behavioral/developmental pediatrician, pediatric neurologist, or, most appropriately, a multidisciplinary team.
  • Exclude suicidal behavior, self-harm, and a strong family history of suicide before treatment with paroxetine.


No specific dietary recommendations have proven efficacy in selective mutism.



Encouragement of continued normal activity is important to prevent behavioral and physical regression in skill levels in individuals with selective mutism.

Contributor Information and Disclosures

Bettina E Bernstein, DO Distinguished Fellow, American Academy of Child and Adolescent Psychiatry; Distinguished Fellow, American Psychiatric Association; Clinical Assistant Professor of Neurosciences and Psychiatry, Philadelphia College of Osteopathic Medicine; Clinical Affiliate Medical Staff, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Consultant to theVillage, Private Practice; Consultant PMHCC/CBH at Family Court, Philadelphia

Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Chet Johnson, MD Professor of Pediatrics, Associate Director and Developmental-Behavioral Pediatrician, KU Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies; Assistant Dean, Faculty Affairs and Development, University of Kansas School of Medicine

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

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