In mutism, the child has the ability to converse normally and does so, for example, in the home, but consistently fails to speak in specific situations such as at school or with strangers. The condition is also called selective mutism, to differentiate it from children who are physically unable to speak. Experts believe that this selective problem is associated with anxiety and fear in social situations such as in school or in the company of adults. It is, therefore, often considered a type of social phobia. This is not a communication disorder because the affected children can converse normally in some situations. It is not a developmental disorder because their ability to talk, when they choose to do so, is appropriate for their age level. This problem has been linked to anxiety, and one of the major ways in which both children and adults attempt to cope with anxiety is by avoiding whatever provokes the anxiety. Affected children are typically shy and are especially so in the presence of strangers and unfamiliar surroundings or situations. However, the behaviors of children with this condition go beyond shyness .

These children understand language and are able to talk normally in settings where they are comfortable, secure and relaxed. Over 90 percent of children with mutism also have social phobia or social anxiety, and some experts view mutism as a symptom of social anxiety. Others view it as a separate, but related, disorder. It is not yet understood why some individuals develop typical symptoms of social anxiety, like reluctance to speak in front of a group of people or feeling embarrassed easily, while others experience the inability to speak that characterizes mutism. What is clear is that children and adolescents with mutism have an actual fear of speaking and of social interactions where there is an expectation to talk. They may also be unable to communicate nonverbally, may be unable to make eye contact, and may stand motionless with fear as they are confronted with specific social settings. This can be quite heart wrenching to watch and is often very debilitating for the child as well as frustrating for parents and teachers.

Treatment
Since selective mutism is an anxiety disorder, successful treatment focuses on methods to lower anxiety, increase self-esteem , and increase confidence and communication in social settings. The emphasis should never be on "getting a child to talk," nor should the goal of treatment be for the child to speak to the therapist. Progress outside the clinic or doctor's office is much more important than whether the child speaks during the therapy session. Initially, all expectations for verbalization should be removed. As the child's anxiety is lowered and confidence increases, verbalization usually follows. If it does not occur spontaneously, techniques can later be added to help encourage progress. A professional should devise an individualized treatment plan for each child and allow the child, family, and school to have a great deal of input into the treatment process. Therapy usually involves some combination of behavioral therapy, cognitive behavioral therapy, play therapy , or psychoanalytic therapy, medication, and in some cases, family therapy .

Behavioral therapy
The primary types of behavioral therapy used for selective mutism are desensitization, fading, and positive reinforcement techniques. Desensitization means exposing a child to something that is feared in a gradual way, in order to help the child overcome the fear. Fading therapy is a type of desensitization that creates a series of events or exposures that starts with a situation that is comfortable for the child, such as being alone in the classroom with a parent and playing a board game. New variables that are progressively more difficult are gradually added. For example, having the teacher walk past the room and overhear the child speaking to the parent, and then having the teacher enter the room, and eventually have the child interacting with the teacher in the classroom. Positive reinforcement, or the use of rewards for changes in behavior, should only be introduced after anxiety is lowered and the child is ready to begin working on goals. It is also important to realize that there are many intermediate steps between being mute and being verbal. During the early stages of treatment, nonverbal communication such as pointing, nodding, and use of pictures to express needs, can be encouraged and rewarded. Though some may fear that allowing nonverbal communication will enable the mutism to continue, many therapists believe it is a necessary step for most children with mutism to overcome their communication anxiety in a step-by-step manner.