Pediatric Social Phobia and Selective Mutism Treatment & Management

Updated: Apr 14, 2020
  • Author: Bettina E Bernstein, DO, DFAACAP, DFAPA; Chief Editor: Caroly Pataki, MD  more...
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Approach Considerations

Although behavior therapy, including CBT, integrated behavior therapy, and S-CAT, are standard treatments for selective mutism [22] , other approaches to treatment include music therapy, play therapy, [44] parent-child interaction therapy, short-term psychoanalytic therapy, hypnosis, and a two-session behavior therapy approach using mobile apps. [45]

S-CAT principles include a three-session CBT intervention for the child and parentat home and then extendeds as school-based CBT, as children with selective mutism tend to be most symptomatic in the school environment. Defocused communication as a general treatment principle included six central components:

  1. To sit beside rather than opposite the child;
  2. To create joint attention using an activity the child enjoys rather than focusing on the child;
  3. To ‘think aloud’ rather than asking the child direct questions;
  4. To give the child enough time to respond rather than talking for the child;
  5. To continue the dialog even though the child does not respond verbally; and
  6. Try to receive a verbal answer in a neutral way rather than praising the child. [46]

Technological advances that are promising include the use of mobile apps to assist successive approximation of speech earlier in treatment as a pilot study was able to show improvement after two sessions. [45]


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. [47, 48]

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 especially when used synergistically with cognitive-behavioral therapy (CBT). The doses used in both children and adults can be higher than those used for affective disorders. [49, 50]

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). [51]

  • 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. [52]

  • 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. [51]

  • 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. [52]

  • Modular treatment: A subset of CBT called MATCH-ADTC (Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems) may be an improvement over usual treatment according to one study. Researchers compared modular treatment to multiple community-implemented evidence-based treatments for youth with anxiety, depression, conduct problems, or traumatic stress. Participants were randomized to either MATCH-ADT or community-implemented treatment (CIT). Youth treated with MATCH showed significantly faster rates of improvement over time on clinical and functional outcomes relative to youth in the CIT condition and required significantly fewer sessions delivered over significantly fewer days. Caregiver-reported clinical improvement rates were significantly greater for MATCH (60%) versus CIT (36.7%). [11]



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.



A recent case study article discussed the use of a manualized family-based CBT approach for very young (younger than 6 years old) children who scored in the concern range on a measure of shyness or anxiety as young as 26 months old. [53]

The use of internet-based approaches such as BRAVE has the potential to provide treatment to prevent worsening or additional associated symptoms of anxiety to persons that would otherwise not receive treatment. [54]