Clinical case rounds in child and adolescent psychiatry: commentary on selective mutism.

The essential feature of Selective Mutism (SM) is the persistent failure to speak in specific social situations (e.g., school) where speaking is expected, despite speaking in other situations (American Psychiatric Association, 2000). The disturbance may significantly interfere with educational or occupational achievement or with social communication. The following case is of a girl with a long-standing history of SM who became involved in treatment at a relatively late age. Despite extensive intervention efforts, she remains selectively mute. When discharged from our program, she had exhausted available treatment options. We have questions regarding differential diagnosis, her evolving personality, and any further treatment. Case Presentation Daisy (pseudonym), a 12-year-old white girl, was referred to the Child & Adolescent Mental Health Care Day Treatment Program at a local hospital for longstanding selective mutism. She had not spoken audibly outside of her home since she first learned to talk. She talks to her parents and her twin brother at home in an audible, appropriate voice. She depends on her parents for any verbal communication outside the home while she may use restricted non-verbal communication such as nodding. Daisy avoids any group activities and had minimal interactions with peers. At school she would stand alone at recess. She performs well academically, except for class participation or oral presentations. She has no history of school refusal. Daisy is particular about her attire and food. She wears the same velour clothes throughout the year regardless of weather. She eats about 5 different kinds of food items. These behaviors seem to be related to her difficulties with change, and tactile sensitivity. She has not demonstrated problems separating , or experienced panic attacks. There are no symptoms of depression, although her affect tends to be blunted. With respect to family psychiatric history, her father described himself as shy by nature and reported that he learned to overcome this when entering the workforce. He is currently on an antidepressant for depression and anxiety. Daisy has four half siblings who were reported as shy, but no with history of selective mutism. Her twin brother is described to be an outgoing person with some behavioral problems. Daisy's family tends to be insular with limited social activities. Daisy's developmental milestones were unremarkable, with no problems with speech and language development. She was assessed by a child and adolescent psychiatrist at the age of 11 years at the request of her school, and was …