A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 4-year-old boy presents to the pediatrician's office for a well child checkup. He does not speak during the visit and will not make eye contact. The father explains that the child has always been shy with strangers. However, the child speaks a lot at home and with friends. He can speak in 4 word sentences, tells stories, and parents understand 100% of what he says. He names colors and is starting to recognize letters. However, his pre-kindergarten teachers are concerned that even after 5 months in their class, he does not speak during school at all. The father notes that he is equally as shy in church, which he has been going to his entire life. Which of the following is most likely?
-
A
Child abuse at schoolIncorrect. Abuse is always worth considering but doesn't fit — his silence predates school (also occurs at church) and there are no other red flags; the pattern fits an anxiety disorder.
-
B
Expressive speech delayIncorrect. Expressive speech delay would show limited speech in ALL settings; this child speaks fluently at home in 4-word sentences with 100% intelligibility.
-
C
Normal developmentIncorrect. Five months of complete school silence plus lifelong silence at church is well beyond typical shyness/adjustment.
-
D
Selective mutismCorrect. consistent inability to speak in specific social situations (school, church) for over a month, with normal speech elsewhere, defines selective mutism.
-
E
Autism spectrum disorderIncorrect. ASD involves persistent deficits in social communication AND restricted/repetitive behaviors across all settings; this child communicates fluently with family and friends, making situation-specific anxiety (selective mutism) the better fit.
↑ Tap an answer to reveal the reasoning
Answer: D. Selective mutism is a childhood anxiety disorder defined by the consistent failure to speak in specific social situations (school, public places) where speech is expected, despite speaking normally in other settings (such as home with family). The pattern must last at least one month (beyond the first month of school) and not be better explained by a communication or speech disorder.
This child speaks freely at home in 4-word sentences with full intelligibility, tells stories, names colors, and recognizes letters — all age-appropriate for a 4-year-old. The deficit is purely situational: he doesn't speak at school after 5 months, and is similarly silent at church which he's attended his whole life. This is the hallmark presentation.
Expressive speech delay would show limited speech across ALL settings, not selective contexts. Normal development (just shyness) is ruled out because the silence has persisted for 5 months at school AND lifelong at church — well beyond a typical adjustment period. Child abuse at school is an important consideration in any behavioral change, but here the silence extends to church (which predates school) and there are no red flags for abuse. Selective mutism is treated with CBT (often with desensitization techniques) and sometimes SSRIs in older children.
**Why each option:**
**A.** Abuse is always worth considering but doesn't fit — his silence predates school (also occurs at church) and there are no other red flags; the pattern fits an anxiety disorder.
**B.** Expressive speech delay would show limited speech in ALL settings; this child speaks fluently at home in 4-word sentences with 100% intelligibility.
**C.** Five months of complete school silence plus lifelong silence at church is well beyond typical shyness/adjustment.
**D.** Correct — consistent inability to speak in specific social situations (school, church) for over a month, with normal speech elsewhere, defines selective mutism.