Treating selective mutism in children: a therapist's manual

1. The programme at a glance

Indication. Selective mutism in children aged about 3 to 10, the age range of the published trials: a child who speaks normally in some places, almost always at home, and who consistently does not speak where speaking is expected of them, almost always at school, for more than a month, not counting the first month of school. The programme assumes that at least one parent can take part and that the school agrees to collaborate. Older children and adolescents call for an adapted format (section 40).

Reference model. Behaviour therapy conducted in the consulting room, at home and at school, with the parents and the teacher. The child is exposed to speaking in small steps, by means of three procedures: stimulus fading, which gradually brings a new person or a new place into a situation in which the child already speaks; shaping, which reinforces forms of communication that come closer and closer to speech, from gesture to sound, from sound to word; and reinforcement of each step climbed. The adults learn to talk with the child differently and gradually to stop speaking in their place. This is the common foundation of the controlled trials (Bergman et al., 2013; Oerbeck et al., 2014; Cornacchio et al., 2019) and of the reviews (Zakszeski and DuPaul, 2017; Hipolito et al., 2023).

Format. Twenty sessions, usually one a week, over twenty to twenty-four weeks: eight at school, five in the consulting room or at home with the child, three with the parents alone, one in a public place, and three that combine several places (sessions 10, 18 and 19). Sessions in the consulting room last 60 minutes, the first 90; those at school, 45 minutes, possibly split into two visits. This total follows the evaluated programmes: twenty sessions over twenty-four weeks in that of Bergman et al. (2013), as described by the reference chapter of the online textbook of the International Association for Child and Adolescent Psychiatry and Allied Professions (Oerbeck et al., 2016); one information session, three at home and seventeen at school, over twenty-one weeks on average, in the Norwegian programme (Oerbeck et al., 2016, 2018); sixteen sessions in the Canadian study (Catchpole et al., 2019). Three booster sessions follow, at one, three and six months, and a fourth before the start of the next school year (section 36).

Mechanism targeted. That the child discovers, step after step, that they can speak in front of a person or in a place that used to frighten them, that the anxiety of the moment can be borne and subsides, and that nothing they dreaded happens. And that the adults around them stop making silence effective by answering for them.

The programme's vocabulary. The small-steps ladder is the list of speaking situations to be climbed, from the easiest to the hardest (session 5), and a step is one of them. The thermometer is the scale from 0 to 10 on which the child, or their parent in the case of a young child, rates their fear. Verbal accommodation refers to everything the adults do so that the child does not have to speak (section 5). The forced-choice question offers two answers that the child can give only with a word: "do you want the red one or the blue one?". Defocused communication removes the pressure of eye contact and direct questions without giving up on speech (section 38).

Session	Focus	Session output
1	Assessing with the parents	Dated history, parents' questionnaire, risks checked, recordings requested
2	Meeting the child without asking them to speak	Observation, recordings listened to, worksheet 1 begun
3	At school: meeting the teacher	Teacher's questionnaire, observation, worksheet 4 drafted
4	Parents' session: what the adults say	Accommodations listed, first withdrawal dated, worksheet 3
5	The speech map and the small-steps ladder	Worksheets 1 and 2 filled in, rewards chosen
6	Bringing in the therapist	First sounds or words in the therapist's presence
7	From gesture to voice	The child speaks to the therapist, with the parent out of the room
8	Taking speech to school	The child speaks in a room at school
9	Bringing in the teacher	First word addressed to the teacher, the week's steps on worksheet 4
10	The progress review	Measures repeated, plan for school revised
11	One classmate, then two	The child speaks with a classmate in the room
12	The small group	The child speaks in a group of three or four
13	Out and about: shopping, the telephone, the family	A step done in a public place
14	Entering the classroom	The child speaks in their classroom
15	The voice in class	At least two of the three target situations achieved in class
16	Handing over to the everyday adults	Parents and teacher lead a step on their own
17	The other adults and the other places at school	Canteen, playtime, other staff
18	The child chooses their challenges	A step chosen and prepared by the child
19	Preparing for changes	Worksheet 7 written with the parents and the school
20	Review, plan and celebration	Measures repeated, worksheet 8, boosters dated

What the person takes away. Eight printable worksheets (section 45): three for the child, to be filled in with a parent, three for the parents and the other adults at home, one for the teacher, and one for the whole family at the end of the programme.

What distinguishes this programme from the other manuals on this site. Treating anxiety in children: a therapist's manual devotes an adaptation of a few paragraphs to selective mutism, in its section 33; this manual makes it an entire programme, in which nearly half the sessions take place at school. A child with selective mutism goes to school, school refusal being rare in these children (Oerbeck et al., 2016): what is at stake is speech, not attendance, which falls under Treating anxiety-based school refusal: a therapist's manual. Finally, the cognitive work that is central in Treating social anxiety in adults: a therapist's manual is secondary here: the child is young and does not speak to the therapist at the start, so that all the evaluated approaches rely first on behavioural procedures (Oerbeck et al., 2016).

2. Before you begin

The four preliminary decisions

Is it really selective mutism? A child who is silent at school does not necessarily have this disorder: the sorting is done in sessions 1 to 3 (sections 3 and 8), and it often requires a speech and language assessment and a hearing test.

Does a risk take priority over the programme? A child who can neither ask to go to the toilet nor say that they are in pain, bullying, signs of danger, or suicidal ideas in an older child each have their own course of action in section 10.

Can the parents commit? The programme assumes that a parent will come to a dozen sessions (section 15), accompany the child to the first sessions at school, and accept changing the way they talk with the child and for the child. Without that, the steps climbed in the consulting room do not carry over into the child's life.

Can the school take part? You need a teacher who agrees to receive the therapist, follow a written plan and carry out small, prepared steps in class. If the therapist cannot go to the school, an adult from the school, trained and supervised remotely, takes over (section 43).

What this programme does not treat

Generalised silence, or silence that appeared suddenly, a language disorder in the foreground, or autism that explains the silence: each first calls for its own assessment (section 8). A child who no longer goes to school, which falls under Treating anxiety-based school refusal: a therapist's manual. Social anxiety without mutism, which falls under Treating anxiety in children: a therapist's manual or Treating anxiety in adolescents: a therapist's manual.

How to use it

Read the whole manual before the first session, in particular sections 5, 6, 37, 38 and 39. Each session follows the same framework: the aim, the steps, what you say, the common mistakes and the criterion for moving on. The pace is the child's: some sessions are doubled, and a session is validated when its criterion for moving on has been met, not because it has taken place. Warn the parents that the first word addressed to a new person sometimes takes several sessions, and that this delay says nothing about the final outcome.

3. Four presentations not to be confused

A child who does not speak at school may be in one of four situations, which do not call for the same course of action.

Shyness and the time needed to adapt. Many young children remain silent for the first weeks at a new school, hence the exclusion of the first month of school by the classifications (section 7). A shy child warms up as people and places become familiar; a child with selective mutism stays mute in the same places, month after month (Oerbeck et al., 2016). Shyness calls for information and a reassessment a few weeks later.

The silent period of learning a second language. A young child who discovers at school a language they do not speak at home often goes through a normal phase in which they understand and observe without speaking. It calls for patient waiting and language support (section 8).

Selective mutism. The child speaks normally at home and is consistently silent where speaking is expected of them, with an impact on their schooling or their social life (section 7). This is the programme described here.

A disorder that affects speech everywhere. A language disorder, hearing loss, an intellectual developmental disorder or autism limits speech or communication in all places, including at home. These presentations call for their own assessment, and they can coexist with selective mutism (sections 8 and 9).

The three sorting questions

To the parents: "Does your child speak normally at home, and can you let me hear it?" It establishes that speech exists, and the recordings make it possible to judge language without the child having to speak in front of you.

To the teacher: "Since the start of the school year, have you heard this child speak, even in a whisper, to anyone at school?" It establishes that the silence is consistent, and often reveals that the child whispers to a classmate, which will serve as a starting point.

To both: "Since when, and did it come on little by little or all at once?" A long-standing silence with strangers, "he's always been like that", points towards selective mutism; a silence that appeared suddenly points towards another presentation (section 8). For a bilingual child, also ask whether they speak their mother tongue at school when someone speaks it with them.

4. Selective mutism as it is observed

Selectivity. The silence depends on the place, the person and what is expected of the child. It can be very clear-cut, as in the child who talks to their mother in the cloakroom and falls silent as soon as someone approaches, or more nuanced, as in the child who whispers to a friend at playtime and never answers an adult. Many children speak more easily to children than to adults, and warm people who keep the conversation going without demanding an answer change the situation a great deal (Oerbeck et al., 2016). The programme draws up this detailed map of speech, place by place and person by person, in session 5.

Non-verbal communication. It varies a great deal from one child to another. Some point, nod, write, and make themselves understood; others dare neither laugh nor cough in front of others and seem frozen. The latter cannot say at school that they need to go to the toilet, or that they are hungry, thirsty or in pain, which makes the disorder more serious than it seems (Oerbeck et al., 2016) and justifies the measures in section 10.

The child at home. There they are often lively and talkative. This contrast produces misunderstandings: the teacher readily believes that the child speaks nowhere, and the parents find it hard to imagine that their child is silent all day (Oerbeck et al., 2016).

Onset and detection. The disorder usually begins between the ages of 2 and 5, but it is rarely detected before the child starts school (Oerbeck et al., 2016). In a German series of 45 patients, it had begun at around 3 or 4 years of age, and the first consultation took place at 8 on average (Remschmidt et al., 2001): years are lost waiting for it to "pass". The parents' "he's always been like that" suggests an inhibited temperament, that is, a stable tendency to withdraw in the face of what is new (Oerbeck et al., 2016).

What the child says about it. They often find it hard to explain why they do not speak; some older children describe a lump in the throat. Many are afraid of making mistakes and hate being the centre of attention; yet when they finally speak, everyone turns round, which drives them back into silence (Oerbeck et al., 2016).

What looks like opposition. In a study of 130 children, a profile analysis distinguished an anxious group with mild opposition, an anxious group with delayed communication, and a group that was only anxious (Cohan et al., 2008). Its authors think that this opposition appears mainly when the child is pressed to speak while they are afraid to (Oerbeck et al., 2016): it often signals a step that is too high.

The impact. In a school-based study, the children with selective mutism spoke less than their classmates and had more social anxiety and other emotional difficulties; six months later, they were a little better but remained clearly impaired (Bergman et al., 2002). The teacher can assess neither reading aloud nor oral work, the child has difficulty making friends, and they learn that others will speak for them.

5. What maintains the silence

Avoidance brings relief. Each time the child does not answer, the fear that was rising subsides. This immediate relief reinforces the silence: the next time, falling silent comes more quickly. Above all, it prevents the child from discovering that speaking would have been bearable and that nobody would have made fun of them. This is the mechanism common to all anxiety disorders, and it is what graded exposure targets.

Verbal accommodation. Adults and classmates adapt to the silence, out of kindness. A recent questionnaire, designed for these situations, distinguishes four forms: speaking in the child's place, for example ordering for them, accepting whispering, accepting non-verbal communication, and arranging activities so that they do not have to speak, for example by having them excused from giving a presentation (Kamenetskiy et al., 2026). Each of these gestures relieves the child and the adult in the moment, and takes away from the child an opportunity to discover that they could have spoken. The reference chapter describes two opposite risks, speaking for the child or demanding from them speech they cannot produce, both of which can make the disorder worse (Oerbeck et al., 2016).

What the data say about accommodation. Its role is established in anxiety disorders in children in general, and Treating obsessive-compulsive disorder in children and adolescents: a therapist's manual summarises the data in its section 5. In selective mutism, the studies are recent. Measured with a general family accommodation questionnaire, it was frequent in a clinical sample, but unrelated to the severity of the mutism (Fisher et al., 2025); two other studies, cited by Kamenetskiy et al. (2026), did find this link. Measured with the questionnaire specific to speaking situations, in 412 anxious young people, it was clearly linked to the severity of the mutism (Kamenetskiy et al., 2026). This link, observed at a single point in time, does not say what causes what. Reducing it is part of all the evaluated approaches (Oerbeck et al., 2016); its own weight in the outcome of treatment has not been measured.

Pressure and the spotlight. Insisting, pleading, promising a reward on the spot, scolding or saying "you can talk, I've heard you" increases fear at the very moment speech is being asked for. Conversely, speech greeted with exclamations puts the child at the centre of attention, which is what they dread most. Both make silence safer than speech.

The role of "the child who doesn't talk". Over time, everyone expects silence, and speaking would become an event. The longer the silence lasts, the more entrenched it becomes: in adolescents, a recent review describes a long history of silence reinforced by the accommodations of those around them, and a disorder that is more resistant to treatment (de Jong et al., 2026); in children, an older age at the start of treatment goes with a poorer outcome (Oerbeck et al., 2015, 2018).

Vulnerability factors. An inhibited temperament, social anxiety in the family and language difficulties make the child more vulnerable; starting school, migration or a new language can trigger the disorder (Oerbeck et al., 2016). In a series of 30 children, social anxiety in a first-degree relative was found in 70% of families, and selective mutism in 37% (Black and Uhde, 1995). Treatment does not seek to change temperament: it targets what maintains the silence today, and a developmental difficulty receives its own help (Oerbeck et al., 2016).

These mechanisms form the circle you draw with the parents in session 4; to the child, they are explained more simply in session 5.

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