DIAGNOSIS AND TREATMENT OF ELECTIVE

MUTISM IN CHILDREN

Evelyn Browne) M.S. W.) Viola Wilson) M.S. W.) and

Paul C. Laybourne, M.D.

Periodically, children are seen in psychiatric facilities who refuse to

speak in school and to strangers, but who can and do speak to certain
specific people, usually one or both parents, and sometimes peers.
Nearly always, these children speak to their siblings. Elective mutism
is the diagnosic term that we have applied to this behavior. This
definition excludes all other forms of mutism, including hearing loss,
schizophrenia, hysterical aphonia, and aphasia. The children with
elective mutism are characteristically immature; most of them have
average or above average intelligence and do not seem to suffer from
any organic disorder.
REVIEW OF LITERATURE

Although it is our impression that elective mutism is not an un-

common disorder, it is one that has been largely neglected in the
American. literature. Our review of the literature includes German
articles and articles published in English. In a historical survey of the
German literature, von Misch (1952) reports that in 1877 Kussmaul
used the term "aphasia voluntaria" to describe mentally sound per-
sons, who forced themselves into mutism for purposes they refused to
disclose. From 1877 to 1936, the description of mutism cases was
sketchy. In 1936, Waterink, Vadder and Weber all offered classifica-

Dr. Laybourne is Director of the Division of Child Psychiatry, University of Kansas

Medical Center, Kansas City, Kansas. Evelyn Browne and Viola Wilson are social workers
on the staff of the Division.

605
606 Evelyn Browne et al.

tions of mutism. However, these classifications seemed to be based

more on precipitating factors than symptomatic manifestations. In
1944 Spieler reviewed fifty cases of mutism and stated that the neurotic
personality was the outstanding feature in the mute children. In 1945,
Tramer interpreted the infantile shyness of mute children in the
presence of strangers as "an archaic defense reflex retained abnormally
long." Von Misch described four cases of elective mutism and com-
pared them with four of Weber's which had been published in 1950.
Some of von Misch's observations were: (1) environmental factors
may precipitate mutism; (2) mutism often occurred upon the child's
separation from the family, especially at the time of his entry into
school; (3) while possibly heredity and intelligence might play some
part, the disorder was basically psychogenic; (4) all cases demonstrated
excessive ties to the mother; (5) the selection of mutism as a symptom
was possibly related to a traumatic experience at the time that the
child was developing speech. Therapeutically, von Misch recom-
mended changing the child's environment by placement, giving in-
structions of a therapeutic nature to the persons who would care for
the child when he returned home, adequate treatment of the neurosis
itself, and speech exercises. Glanzman described the "anal sulker"
syndrome, the three main symptoms being, (1) mutism, total or elec-
tive, (2) urinary retention, (3) voluntary retention of stools.
Leaving the German literature and turning to articles published in
English, D. ]. Salfield (1950) made the following observations: The
onset of elective mutism occurs between three and five years of age;
there is no mental defect; there frequently seems to be a familial
factor; there is relatively great resistance to treatment; and there may
be an early somatic, psychological, or compound trauma. Adams and
Glassner (1954), in the United States, seem to have included some
cases which we would have excluded by definition. They particularly
emphasized that the children in their cases came from severely dis-
turbed home situations, were unable to develop trust in their parents,
were slow in toilet training, and despite their ability to hear and
understand the spoken word, used pantomime and a peculiar sign
language to communicate.

GENETIC AND DYNAMIC FORMULATION

It would appear that most of the published material concerning

Elective Mutism 607

elective mutism focuses on the psychopathology of the child. Although

many of the reports make reference to the family, they are sketchy and
incomplete. The therapeutic focus remains on the child and treatment
consists of doing things with him and to him. If therapy of the parents
is mentioned, it seems to be of an instructional or pedagogic nature.
Our experience with ten cases of elective mutism, observed during
a twelve-year period, has led us to formulate the problem in different
terms. If one makes an intensive study of the entire family, it becomes
apparent that the symptom in these children represents not only in-
dividual psychopathology, but family psychopathology. We have been
impressed repeatedly with the tendency of these families to be split
into two factions with the identified patient firmly allied with one
parent, usually the mother, in a tight symbiotic relationship. This
symbiosis between mother and child is related to the hostile and dis-
appointing relationship that the mother has with the father. This has
been described in different ways in a number of our cases. For ex-
ample, in our earliest case, one of the observations recorded in the
chart is: "For all practical purposes, this household is divided into
two sets, the mother and Tommy (the patient) and the father and
John." The same concept is expressed in another of our cases by:
"The father's work takes him out of the home most of each summer
and the mother deeply resents this, although she has felt unable to tell
him of her feelings. The mother fears to express her anger to her
husband, because he then punishes her by refusing to talk to her
several days at a time. In her relationship with the patient, the mother
has infantilized him and while she resents his constant demands on
her, she is not able to refuse him. She caters to him, allows him to hit
her, and is dominated by him." Here again, we have the dissatisfaction
of the wife with the husband, and the symbiotic infant-like relation-
ship between the mother and child.
We have some evidence to indicate that these children may experi-
ence a traumatic event at the time speech is forming which is, theoreti-
cally, a critical phase of speech development. One of our children was
hospitalized with acute giant urticaria at the age of twenty-two months,
and it was after this event that his tendency to speak to fewer and fewer
people developed. Another child at two and one half years of age was
grabbing at her mother, who was pregnant at the time; her father
scolded her quite severely for the action. She immediately ceased
 608 Evelyn Browne et al.

talking to her father and did not speak to him until the time of her
psychiatric evaluation nine years later.
With the fixation or regression to the level of beginning speech de-
velopment, the child behaves like a two-year-old in other ways. A
\ typical description of one of the children indicates that he was a shy
boy, who would not talk to strangers. He would appear to be very
timid, would hang his head, and would not be able to look people in
the eyes. However, he would always talk to children in the neighbor-
hood and would actually seek them out to play with. It is well known
that two-year-old children often behave in this shy, reticent way
around strange adults and are afraid to speak at these times.
The electively mute child seems to be afraid of the sound of his
own voice. One of our patients had to give a talk at school. She taped
the material, took the recorder to school, and fled from the room after
turning on the recorder.Jf'he hostile retentive aspects of this mutism
are difficult to overlook. The refusal to speak to someone that we are
angry with is well known in our culture. Adults frequently use this
method of expressing hostility to each other. These children seem to
punish their parents by refusing to talk to them-Many of these chil-
dren stop talking to a parent, particularly the father, after he has
punished them in some way. The mothers get a vicarious pleasure
from this behavior in their children and we have evidence that they do
little to discourage and probably much to encourage it. Thus, in the
study of the family, the genesis of the behavior can be understood. The
neurotic interaction of the family members is such that it preserves
the symptom indefinitely.

IMPLICATIONS FOR THERAPY

It would appear that elective mutism, like many other psychiatric

symptoms, responds to a number of different types of therapy in some
cases, while in other cases the results are disappointing. In reviewing
the literature, it was our impression that the long-term results of treat-
ment by the methods described were not very satisfactory. Our own
treatment program has undergone an evolution, as has much of child
therapy in general. The first case that we worked with therapeutically
was treated with the traditional child guidance methods of that day.
We worked directly with the child, utilizing the services of two
trainees in psychiatry, while the mother was seen by a social worker.
Elective Mutism 609

After a year and a half of disappointing results, the boy was hospital-
ized and given an injection of Desoxyephedrine and Amy tal in an
attempt to break through his mutism. The result of this injection was
some silent crying; otherwise the effort was futile. Fortunately, during
his hospitalization, we were able to ascertain that he had a severe
articulatory problem and referred him to our speech clinic, while we
continued with his psychotherapeutic work. He formed a strong re-
lationship with his speech therapist, who taught him speech sounds at
a sotto voce level. Finally he began to talk with her, then with the
people in the speech clinic, later, with everyone who was unaware that
he didn't talk. However, he continued not to talk in school for nearly
a year. It was decided by the psychiatric personnel, the speech person-
nel, and the child that it would be helpful for his speech teacher to go
to school with him and show the children how he could talk. This was
done, and the boy talked. He became the class hero with his triumph
over silence of twelve years' duration. As far as we were able to as-
certain, he continued to talk adequately after this experience. It was
difficult to assess what, if any, effect we had on altering the difficulty
between the parents.
As our experience increased, we discovered that the treatment of
elective mutism was difficult, long, and involved. We gradually learned
that it is frequently necessary to involve the mother, father, and child
in an intense therapeutic relationship in order to resolve the kinds of
problems which exist in these families. Therapy must be directed to-
ward helping the mother and father to clarify their relationship with
each other, as well as with the child. The child needs to be helped to
resolve his anxious, hostile relationship toward his parents and adults
in general, and to give up his neurotic mechanisms in order to mature
psychologically. The following case will illustrate a number of these
points.
CASE REPORT

Billy seemed to develop normally in the early months of his life. He

said words at eight months and simple sentences at eighteen months,
but never used personal pronouns. Temper tantrums appeared at
sixteen months. The parents reacted differently to these, the father
becoming angry and the mother trying to reason with the child. A
maid who came in twice a week seemed best able to deal with Billy
610 Evelyn Browne et al.

and his angry outbursts. At the age of sixteen months, Billy developed
urticaria that was present during the day, but disappeared during the
night. At twenty-two months, he was hospitalized for four days with
acute urticaria, which was generalized and severe. Billy cried for
eighteen hours without resting after being taken to the hospital. He
wanted to turn the lights off and on constantly and to drink from the
water fountain. No one was able to quiet him until, finally, the maid
was called to the hospital and Billy stopped crying. The following day,
when mother appeared, Billy immediately began screaming and be-
came upset. At the age of three, Billy stopped talking to the nurse
upon visits to the doctor's office. At the age of three-and-a-half, when
the mother was in the hospital for the birth of the younger sister, Billy
refused to talk to the aunt who cared for him. From that time, he
became more selective of people to whom he would talk, eventually
narrowing it to his immediate family, his two grandfathers, and neigh-
borhood children, but only with the latter if they played without adult
supervision. He would talk on the telephone to some adults to whom
he would not talk in person. At the age of three-and-a-half, Billy be-
came identified with Roy Rogers, and his sentences changed from
"Billy wants" to "Roy wants." He would only answer to this name and
had a cowboy hat from which he was inseparable. The parents felt he
carried the pretense too far, seeming to live in a world of his own.
At the age of four, his previous good toilet training broke down and
he became enuretic at night. At the age of five, he was evaluated by the
speech department. They found he was intellectually within normal
limits and that he suffered from no speech pathology other than his
mutism. Prior to coming to child psychiatry at the age of six, he was
seen by a psychiatrist in private practice who tried working with Billy
by also being mute. This was discontinued as Billy began screaming
from the time they stopped at the doctor's office and had to be forced
into the interview. Billy did not speak in class or on the playground
during his kindergarten year, but asked his mother for a magic toy to
make him talk at school. It is interesting that she seriously considered
giving him a toy.

Treatment of the Child

The decision of our diagnostic team was to attempt treatment of
Billy on an outpatient basis, while he remained in his own home and
Elective Mutism 611

in public school classes. He has been seen for twenty-seven months

with a total of 125 treatment hours. For the first thirteen months of
treatment, there was difficulty in separating the boy from his mother.
It appeared that the mother clung to him as much as he clung to her.
Initially the therapist assured Billy he would not be pressured to talk.
The first eight hours were characterized by passive, immature and dis-
organized play. Always he came with his pockets full of bits of paper
and string, which he began to show to the therapist after about ten
hours. By then he felt secure enough to begin hammering with his fists
on the steel cabinets and on the screen and the window. The therapist
permitted this behavior, but interpreted the angry feelings revealed.
With this Billy became more aggressive and began throwing the ball
at the therapist. Then he used the ball in many ways, to masturbate,
to get bodily contact with the therapist, to show her where to go for the
hour, etc. At this point, it was necessary for her to prevent Billy from
'Smearing paint or glue on her. The earliest communications with the
therapist were animal sounds and "yes" and "no" sounds, which Billy
made with his head in the waste basket. Later, written notes were
passed back and forth in the playhouses under the table. Next, he
moved out to the blackboard. As his play became more integrated, he
showed distinct regressive behavior with his therapist. He wanted
more bodily contact. He would cling to her back or legs, would find
opportunities to explore the therapist sexually, the latter behavior
being limited repeatedly. He began to lie flat on the floor and close his
eyes; next, he moved to lie across the legs of the therapist. After seven
months of treatment, he urinated in the playroom. Three weeks later,
while allowing himself to be held in the therapist's arms for the first
time, he soiled. Following this, he wanted to be pushed around the
playroom on a roller chair, while he held his head back against the
therapist. It was much like pushing a baby in a buggy. After nine
months of no verbal communication other than that described above,
the therapist began to feel angry and frustrated with Billy and told him
so. He then began a limited speech in a falsetto voice. At the end of
the year, he was building with bricks and beginning to make crude
models with the train tracks and cars. He no longer fought limitations.
He had stopped wetting the bed. After thirteen months (80 hours), a
decision to attempt to re-enact the traumatic hospital experience was
decided upon. The playroom was set up for a hospital scene. A doll was
612 Evelyn Browne et al,

placed in the crib, and an intravenous set was obtained with a hypo-
dermic needle attached. He reacted to this by treating the doll with
injections and sugar pills. Fascinated, he continued this play for the
next three hours. Following the second hour, he broke out in giant
urticaria, which lasted for the rest of the day. This was the first time
he had experienced urticaria since he was in the hospital at the age of
twenty-two months. The change following this spectacular physiologi-
cal regression was marked. In the third hour, Billy began talking freely
in a normal voice. Once he had begun talking, he manifested resistance
to coming to therapy. He told the therapist that his house had burned
down and that he was moving away. The resistance lasted for the next
five weeks; then he began playing out some of the problems related to
his home. His father had no car license, he had to go to jail, he had no
money, etc. The ball had been neglected for the previous several
months. He began playing with it again, but it was no longer used for
bodily contact. He no longer behaved like a baby during his thera-
peutic hour.
For the last seven months, Billy has worked through such things as
cheating in play. He has begun talking to the children in school and
reading in a very low voice . He had one reoccurrence of bed-wetting
after three canceled appointments which had not been explained to
him by his parents. During his therapy hours, he has begun to verbalize
his feelings. For the last six months, he has been going outside of the
playroom for part of each hour. When he first began going outside of
the playroom, he would not talk; then he began talking if there were
no others around. Later, he would speak while in the coffee shop when
there were no strangers around. Now he will talk with the therapist in
the waiting room. Most recently, there was a three-way conversation,
including his mother. His behavior has improved markedly in all
spheres. He has become a leader with the children and does average or
above average
l
work in school. He is including all relatives in his con-
versation. The teacher reports Billy has begun talking in the halls and
in line, both places where speech is forbidden.

Treatment of the Mother

The mother was seen twice weekly for the first six months and has
been seen once weekly for the past year and a half. In the early sessions,
separation of the mother and child for the therapeutic hours was
 Elective Mutism 613

marked by extreme difficulty. She was tense and anxious and com-
plained that she could not remember details about anything. It was
difficult for her to express and clarify her feelings, The only emotion
she could clearly identify was the intense anger that she experienced at
certain times when she would lose control. This was dealt with and
worked through during many therapeutic sessions with support, clari-
fication, and interpretation. The mother became free enough to dis-
cuss her real feelings about her relationship with her husband, and her
own personal conflicts. She had a deep resentment toward her husband
which she was unable to express verbally in any constructive way and
which came out in periodic explosive outbursts.
Because of her frustration with her husband, the mother had devel-
oped a symbiotic-like relationship to Billy. In the past she had sobbed
and clung to him in an attempt to deal with her feeling of disappoint-
ment in her husband. Billy and his mother seemed to team up against
the father in their anger. At times Billy was mute and closed up when
in the presence of his father. There was a seductive quality in the
mother's behavior with Billy, which she probably could not resolve
until a more satisfactory relationship with the father was developed.
Mother was helped to allow Billy to establish independence in areas
where he seemed competent and to recognize these instances where his
need was for her to be more giving and supporting. Separation became
less of a problem as she was able to recognize her own feelings of want-
ing and needing the child to cling to her. Firmness and consistency
were hard for the mother to develop, but as she worked at it, she began
, to experience results, and Billy began to show a gradual increasing ma-
turity. Mother then began to experience great relief of tension around
her new-found ability to express her anger toward the clinic personnel
for allowing her husband to "goof off," get out of therapy hours, and
act out his feelings against therapy. She complained that he felt,
"there's nothing wrong with me, it's you and Billy." She stated that
the father used his therapy hours to "be a buddy with the therapist."
The case was reviewed and the staff felt that the father probably was
improperly assigned to an inexperienced therapist; in view of the na-
ture and depth of his psychopathology, it would be reasonable to assign
him to a permanent staff member. At this point, the mother's therapist
also began to work with the father. Immediately, the mother began to
make considerable improvement in her own therapeutic hours.
614 Evelyn Browne et al.

For the past year the mother and father have been seen by the same
therapist. This has proven to be a most successful way to work with
these parents. The neurotic interaction between them was often so
subtle and both parents used denial so effectively, that it was almost
impossible for the therapist working with only one parent to under-
stand and deal with the distortions that they brought to their thera-
peutic hours.

Therapy with the Father

In the early hours of the father's therapy, he was assigned to pedi-
atric residents rotating through child psychiatry. The relationships
were superficial. He limited his discussions to the problems with his
son and his basic difficulty was never dealt with. He was next assigned
to a psychologist trainee at the time the family was undergoing a seri-
ous financial crisis. The father had gone into business for himself and
it had failed; neither the father nor his therapist could bring them-
selves to discuss this material and its meaning. The fee the family was
charged was unrealistic and the amount they owed the clinic was in-
creasing rapidly. Attempts were made to get the father's therapist to
deal with this. However, before this was resolved, the therapist, be-
cause of a personal matter, was unexpectedly forced to terminate his
relationship at the clinic. The father was then assigned to his present
therapist, who was also the mother's therapist. We knew from the
mother that the father was acting out his conflicts. He was writing bad
checks and was seriously in debt, thus threatening the financial integ-
rity of the family. Since we felt it was undesirable to cross-communi-
cate this material, we decided to deal with the realities of the debt to
the clinic. The fee for therapy was reduced to a token payment, but it
was clearly defined with the father that this obligation must be met.
The father continued to forget to pay his therapy bill and when it was
discussed with him, there was always an excuse. It became necessary
for the therapist to remind the father in each session that he must pay
the bill, and later it became necessary for her to accompany him while
he paid his bill. Even then there were repeated attempts to escape by
not having the correct change, trying to cash a bad check, etc. The
therapist felt considerable embarrassment about finding it necessary
to make the father pay his bill and the effect of his behavior on her was
discussed with him. The father tested the limits in the same way a
Elective Mutism 615

small child would, and only by setting definite limits and rigidly in-
sisting that they be carried out was the therapist able to establish a rela-
tionship that ultimately proved to be therapeutic. The father began to
work in his therapeutic hours. It became clear that he equated love and
money, and that most of his acting out had been centered around this
conflict. He was then able to talk about his discovery at the age of four-
teen that his father was not really his father, but his stepfather. Until
this time, he had always been industrious and hard-working, but he
suddenly changed and began to spend the stepfather's money recklessly
and became a "playboy." It would appear that he was attempting to
punish his stepfather for having concealed this fact from him. When
he was able to discuss this, he began to handle his money better, but
this was not to be the end of his acting out regarding his clinic bill.
He wrote a bogus check to the clinic on a bank where his wife had an
account, but he did not. It was decided that we would deal with this
by means of a family conference, attended by both parents and their
therapist, the child's therapist, and the clinic director. The mother
was unaware of the fact that he had written a bad check to the clinic,
but on many previous occasions had either picked up his bad checks
herself, or had persuaded her husband's father to do so. In the confer-
ence, the self-destructive quality of the father's behavior and the moth-
er's contribution to it was discussed with them. It was clearly stated
that the therapists were "about at the end of their rope" and that if the
father was trying to convince them that it was useless to work with him,
they were about convinced. We stated clearly that this kind of activity
must stop, because it was destructive to him and that we could not per-
mit it. We again stated that the bill would have to be paid each week,
and a regular fixed amount toward his outstanding balance would have
to be paid.
Since the conference, the father has met these requirements, except
on two occasions when he was not able to make a payment on the bal-
ance. He did not, however, try to "get by," but discussed his financial
situation with us in a realistic way. In his therapeutic hours, he began
to verbalize his feelings and developed considerable insight into his
lifelong behavior disorder. He has been working regularly as an insur-
ance salesman and paying on the numerous bills that he had incurred.
It is our opinion that he is definitely attempting to work out his prob-
lems now. Recently he asked for a joint interview with his wife to dis-
616 Evelyn Browne et al.

cuss their mutual problems. There would appear to be a direct corre-

lation between the improvement in the father and the improvement
in the child. It was apparent from the work with the child that he was
aware of his father's financial difficulties and dishonesty. He verbalized
it very clearly in the play sessions, and when his father began to meet
his responsibilities in a more mature way, the boy became more re-
laxed and therapy with him progressed much more rapidly.

IMPLICATIONS FOR THE SCHOOL

In our work with children exhibiting effective mutism, we have

noted that the reactions of the school seem to follow a definite evolu-
tion. It would appear that, generally, the school identified with the
child in his anxious and withdrawn behavior. Many times the teacher
made no attempt to indicate to the child that she expected him to talk.
She stopped giving him opportunity to talk by falling into the same
pattern that so many other people in the child's life utilized. She ac-
cepted him as a nonspeaking child, responded to his pantomime re-
quests, and generally treated him differently from the other children.
In our experience, after this has gone on for a period of months or
years, eventually someone in the school reacts with frustration and
anger; then overt attempts are made to insist that the child talk. These
attempts are usually met with panic and increased resistance by the
child, so that often an impasse is reached between the family on one
hand and the school on the other. The school insists that the child talk,
or not be promoted to the next grade. Probably these patterns of reac-
tion contribute something to the continuing pathology. We have no-
ticed that when the teacher patiently but clearly indicates to the child
that she expects him to talk, he has an increased tendency to do so. This
is also true in the therapeutic sessions. It is our opinion at this time
that close work with the school, and early referral of these cases by the
school, is beneficial to all parties involved.

DISCUSSION

As we have become more experienced in dealing with the problem

of elective mutism, it appears to us that this disorder has certain
unique features and certain features in common with other neurotic
disorders of children. These children appear to be either fixated or
~·i
Elective Mutism 617

regressed to the anal stage of development. They frequently have uri-

nary and bowel difficulties at this time; wetting and soiling persists
longer than would be normally expected.cThese children are negativ-
istic, shy, and withdrawn. Their manifest behavior in many ways re-
minds one of a child of about two, who cannot speak to people other
than those with whom he is familiar. He regards people, other than
his immediate family, as strange and frightening. In addition to this,
these children seem to develop an intense negativistic and sadistic rela-
tionship toward most adults. They utilize muteness as a weapon to pun-
ish people who have offended them. 'Parents of these children are un-
happy in their marriage, and the mothers utilize the children to attack
the fathers. Although many therapists probably would not use the spe-
cific methods that our clinic has found useful, it would appear that the
resolution of the difficulty in the child rests on the successful treatment
of the parents, as well as the child. In our opinion, one must be pre-
pared to deal with serious psychopathology in the parents of these chil-
dren. Flexibility in treatment design needs to be maintained. Family
conferences, joint interviews, treatment of both parents by the same
therapist all need to be considered and utilized where therapeutically
indicated.

SUMMARY

We have presented and discussed the dynamics of elective mutism.

We regard it as a family neurosis and feel that the symptom can be
understood only by studying the entire family constellation. Thera-
peutic work with all three members of the family is indicated. Close
liaison with the schools is extremely helpful, and the schools can play
an important role in early case findings and referral to psychiatric fa-
cilities.

REFERENCES
ADAMS, H. M. & GLASSNER, P. J. (1954), Emotional involvement in some forms of mutism..
l- Speech & Hearing Disorders, 19:59-69.
SALFffiLD, D. J. (1950), Observations on elective mutism in children. l- Ment, Sci., 96:1024-
1032.
VON MISCH. A. (1952). Elektiver Mutismus im Kindersalter. Z. Kinderpsychiat., 19:49-87..