P3B365: Selective Mutism After Verbal Reprimand in a 3-year-old: A Case Report

Introduction: Expressive language plays a crucial role in the development of children. Inability to communicate effectively can have a debilitating impact on the psychosocial and academic functioning in childhood. Such is the case in selective mutism where a child fails to speak in settings where speech is expected. It is a relatively rare disorder with a prevalence of 0.7 - 2%. The case below describes a 3-year-old male diagnosed with selective mutism.

Case Description: A healthy three-year-old male with history of expressive language delay was brought by mother due to child's "refusal to talk". The child has been improving in terms of speech without need for early intervention and then suddenly did not talk. It started 2 months prior after patient was scolded by his uncle in front of relatives, after throwing away his food during a family gathering. He does not speak to anyone and would only grunt and use hand gestures to communicate. He has good eye contact and can follow commands. Other aspects of his development are at par with age. Mother denies head trauma and other symptoms. Birth, past medical, and family history were unremarkable. Physical, audiologic and neurologic examination were normal. He lives with his parents in a Spanish-speaking household and had limited social interaction with other children. He just started daycare 3 months prior and teachers perceived him as very shy. He did not participate in group activities and noted to be wetting himself a few times due to failure to communicate verbally with teachers. Patient was referred to a developmental pediatrician and was diagnosed with selective mutism. He underwent weekly psychotherapy and noted to be speaking to parents and teachers but still not talking to other children or strangers.

Discussion: Selective mutism, an uncommon childhood anxiety disorder, is usually diagnosed between 3 to 6 years old. The child experiences a trigger event, which in this case is a verbal reprimand causing embarrassment. Children may be perceived to be extremely timid or have intentional "refusal to talk" but they simply are unable to speak. Symptoms vary in each individual case and could present as mute in all situations or with selected people. Some children might appear stiff while others use nonverbal communication. Criteria for diagnosis include symptoms for at least one month and not including first month of school. The heterogeneity of presentation necessitates targeted multimodal treatment which could include parent-child interaction therapy and cognitive behavioral techniques.

Conclusion: Various risk factors, triggers, and symptoms in selective mutism should be known to pediatric providers in order to identify patients and provide anticipatory guidance. Stressing the importance of early intervention and participation of family and school in the treatment process can aid in mitigating effects on psychosocial and academic progress.