CHALLENGING CASE: DEVELOPMENTAL DELAYS AND REGRESSIONS Selective Mutism*

CASE Peter’s parents made an appointment with his pediatrician because of their increasing concern about his refusal to speak. After approximately 2 weeks following the start of a new preschool, Peter, 4 years 10 months old, refused to speak to other children or the teacher. During the first week of school, he found it difficult to separate from his mother or father. He would cry and cling to them while asking to go home. This difficult separation experience gradually subsided by the beginning of the third week and corresponded with the onset of mute behavior. At home, he spoke only to his mother, with a clear speech pattern and full sentences. He limited his responses to his father or two older siblings with body gestures. He appeared to hear well and understand verbal directions. Peter’s parents described him as a shy child who eventually makes friends and plays interactively. His play, both by himself and with others, is filled with imaginary activities. There have not been any disruptive behaviors at home or with friends. Peter’s gestation and birth were uneventful. Motor milestones were on time. At 18 months, he spoke only five words; at 24 months, he spoke 10 words. Two months after his second birthday, he was speaking with clear and elaborate sentences. Physical examination revealed a normal office screening audiogram (25-dB threshold from 500–3000 Hz) and the absence of dysmorphic facial features, cleft palate, middle ear fluid, or a neck mass. Compliance of the tympanic membrane on pneumo-otoscopy was normal; this was confirmed by normal peaks on tympanometry. Peter’s oropharynx, epiglottis, and uvula were easily visualized and found to be normal. His facial features, body movements, and responses to his mother’s commands were consistent with intact auditory receptive function. In the office, he was calm and remained close to his mother. His family drawing revealed age-appropriate fine motor and visual-perceptual skills. All members of his family were drawn with distinctive differences in size. Peter was at one end of the family group, standing next to his mother. During a 20minute office assessment, the pediatrician was unable to engage Peter in spoken speech.