Pediatric Social Phobia and Selective Mutism Clinical Presentation

Updated: Apr 14, 2020
  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD  more...
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Careful attention to a history of caffeine overuse can be helpful, as caffeinism commonly mimics symptoms of anxiety. The family history often includes anxiety disorders (both social phobia and selective mutism). Selective mutism may frequently coexist with other speech and language disorders (eg, expressive-receptive language disorder, expressive writing disorder). Social or performance situations (eg, public speaking, performing in a school play) are typically avoided (or barely endured) by persons with social phobia and those with selective mutism.

DSM-5 diagnostic criteria for persons younger than 18 years state that, to be considered selective mutism, symptoms must persist for at least 6 months, must not be due to the direct physiological effects of a substance (eg, caffeine) or to a general medical condition, and must not be better accounted for by another mental health disorder (eg, depression, acute psychosis). [1]

The Bayley-Infant Neurodevelopmental Screener is commonly used in children younger than 3 years who generally have low birth weight and suspected intellectual disability. [23]



Children with selective mutism may have a possible higher risk of electroencephalographic abnormalities that may reflect an eventual diagnosis of benign epilepsy of childhood or a more complex organic brain disorder. [24]



The etiology of selective mutism is multifactorial. Some children develop selective mutism after a stressor such as illness, separation from their caregiver, or other traumatic experiences such as abuse or neglect and bullying can especially contribute risk and also occur related to the lack of a large supportive peer group. This is because youth with selective mutism are not as likely as "normal" unaffected peers to be protected by peer bystanders from being targeted and victimized by bullying. [25, 26]

Programs that are effective (such as Olweus, KiVa) to prevent bullying are especially important for youth with social anxiety and selective mutism. A study using structural equation modeling and random assignment to either intervention or control condition of 7,741 students from 78 schools looked at the effects of the KiVa antibullying program on students' anxiety, depression, and perception of peers in grades 4-6; reductions in peer-reported victimization may have predicted changes in anxiety and depression symptoms. [27]

Other children with selective mutism have an underlying language delay or disorder (most often expressive language disorder) or severe social anxiety and shyness. Some children report fearing the sound of their own voice. Adverse peer interactions frequently include peer social rejection and scapegoating directly related to the selective mutism. [28, 29]

Several genetic factors are being studied. (See Pathophysiology)

Instances of family members "speaking for" the children with selective mutism serve as positive reinforcement for not speaking, and this may also be self-reinforcing, as the child does not have to separate from them. [29]

  • Children with selective mutism are at higher risk for developing other developmental disorders, such as enuresis, encopresis, and abnormal EEG findings (because of immaturity), as well as developmental speech and language disorders. These disorders are also associated with increased incidence among first- or second-degree relatives. [29, 30]

  • Mitral valve prolapse has not been associated with anxiety disorders in general and social (anxiety) phobia specifically. [31]

  • A cross-cultural perspective is essential. In Japan and Korea, what persons living in the West classify as social phobia may manifest as persistent and excessive fears of offending others in social situations instead of embarrassment (ie, taijin kyofusho), including fears that blushing, eye-to-eye contact, or one's body odor could be offensive to others. [32]