According to the Selective Mutism Association1, selective mutism is “an anxiety disorder characterized by a person’s inability to speak in certain social settings such as at school, work, or in the community.” It can manifest at any age, but it most often begins in children aged two to four years old. However, the disorder may not become fully recognized until the child reaches nursery or preschool. Selective mutism is not a choice or a result of intense shyness. Rather, individuals with selective mutism are literally unable to speak even when remaining silent can result in negative consequences, like shame, social ostracism, or punishment.
What is Selective Mutism?
Selective mutism is a consistent failure to speak in specific social situations despite being able to talk elsewhere, which explains the “selective” aspect of the condition. Classified as an anxiety disorder, this mental health condition prevents children (or adults) from talking in certain situations because of fear or anxiety. There are varying degrees of selective mutism, from not speaking but participating fully in activities and appearing social to refusing to speak or participate in activities altogether.
Who Does Selective Mutism Affect?
Selective mutism affects about 1 in 140 young children.2 It is most prevalent in young children. However, in rare cases, adults and teens can suffer from this anxiety disorder as well. Expressive/receptive language disorders, as well as communication disorders, may increase the risk of selective mutism in children. Research also suggests that bilingual children may be at a higher risk of developing the disorder compared to monolingual speakers. Although very rare, traumatic or stressful events may be related to the development of selective mutism. However, most of the individuals with the disorder have no history of traumatic life events.
Signs and Symptoms of Selective Mutism
Selective mutism symptoms often manifest when children begin interacting with people outside their immediate family and comfort zone. For example, a child who speaks comfortably at home may suddenly become silent in public settings or around unfamiliar individuals. This silence is often a response to intense anxiety, rather than a lack of language skills, shyness, or defiance. In other cases, children may appear frozen with fear or completely shut down when expected to speak, and they are unable to express themselves even when they want to.
Other indicators can include:
- Struggling to make eye contact when uncomfortable
- Presenting as behaviorally inhibited
- Relying on pointing, nodding, writing, and other forms of nonverbal communication to answer when spoken to
- Speaking through a trusted individual, e.g., whispering an answer to a question to a parent or friend at school
Children diagnosed with selective mutism tend to demonstrate difficulty effectively participating in school or forming friendships with other students their age due to an inability to speak at school or in public. Also, selective mutism symptoms often only occur in specific settings and/or around particular individuals.
Emotional and Social Impact
As we discussed recently with ADHD and connection, mental health disorders can severely impact a child’s ability to socialize or perform in school and other settings. With selective mutism, this is the case in situations outside an individual’s comfort zone. Those affected struggle with speaking in certain situations because of intense anxiety, rather than a language delay, learning disorder, or autism. This fear of speaking can significantly interfere with daily life, particularly in school or other public settings.
What Causes Selective Mutism?
There is no specific cause for selective mutism. In general, it is understood to be “an anxiety disorder related to shyness, social anxiety, and inhibited temperament in which speaking situations are avoided and this avoidant behavior gets reinforced over time.”1
Research also suggests that the following conditions may contribute to a higher risk of selective mutism development:
- A genetic link between children with SM and anxious parents or family members
- A decreased threshold of excitability in the amygdala, the area of the brain that receives and processes signals of potential threats
- Expressive/receptive language and communication disorders
- Being bilingual
Co-occurring Conditions
Is selective mutism a disability? Yes, especially in educational or occupational settings where it significantly interferes with communication and daily functioning. There are correlations between the disorder and other mental health disorders, such as selective mutism and autism spectrum disorder. The relation isn’t causal. Rather, it’s just more likely that children with social mutism also suffer from other conditions, such as:
- Social anxiety disorder (most common)
- Other anxiety disorders
- Phobias
- Autism spectrum disorder
- Separation anxiety
- Post-traumatic stress disorder (PTSD)
How is Selective Mutism Diagnosed?
Selective mutism is a mental health disorder that requires diagnosis by a trained professional using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. A selective mutism diagnosis must meet the following criteria:
- There is a consistent failure to speak in specific social situations where it’s expected, such as school, despite speaking in other situations.
- The silence interferes with educational or occupational achievement or social communication.
- The inability to speak in social situations extends beyond at least a month (i.e., it continues after the first month of school).
- A failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
- A communication disorder (e.g., stuttering) or another mental disorder, such as autism, schizophrenia, or another psychotic disorder, does not better explain the behavior.
DSM-5 Diagnostic Criteria
To further explain the selective mutism meaning and help health professionals make a diagnosis, the individual should meet the following criteria:
- There is a consistent failure to speak in specific social situations where it’s expected, such as school, despite speaking in other situations.
- The silence interferes with educational or occupational achievement or social communication.
- The inability to speak in social situations extends beyond at least a month (i.e., it continues after the first month of school).
- A failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
- A communication disorder (e.g., stuttering) or another mental disorder, such as autism, schizophrenia, or another psychotic disorder, does not better explain the behavior.
Professional Evaluation
Selective mutism is often diagnosed by an individual’s primary healthcare provider, such as a pediatrician. To reach a diagnosis, they will ask you about your child’s signs and symptoms and review their medical history. They will also review your child’s speech and language development. Bringing your child’s academic reports and teacher comments to the appointment is often helpful. In some cases, the healthcare provider may also want to observe your child at both home and school, or request a video if an in-person evaluation isn’t possible.
Other medical exams may be conducted, such as a neurological exam or a hearing test, as well as an examination of the child’s ears, lips, tongue, and jaws. Overall, the healthcare provider wants to rule out other medical conditions, such as schizophrenia. They may also seek help from other healthcare providers, like a speech-language pathologist (SLP), psychologist, or psychiatrist. The SLP can assess your child’s ability to understand and use language, and a psychologist can investigate emotional issues that may cause the condition.
Treatment and Therapy for Selective Mutism
Most children can overcome selective mutism with appropriate handling and treatment. As with most mental disorders, early intervention is best, as the later the diagnosis occurs in life, the longer treatment may take. The effectiveness of the treatment will depend on several factors, including the duration of symptoms, whether there are additional communication/learning difficulties or anxieties, and the involvement and cooperation of all parties involved.
Cognitive Behavioral Therapy (CBT)
CBT is generally the first-line treatment for selective mutism, and it focuses on identifying and changing unhelpful thought patterns and behaviors that contribute to anxiety. When treating selective mutism, CBT helps individuals become more aware of their anxious thoughts about speaking and understand how these thoughts influence their feelings and behaviors. Then, through gradual, structured exposure to speaking situations they find challenging, individuals can build confidence and reduce anxiety over time.
Speech-Language Therapy
Speech therapy can help individuals overcome any underlying speech problems, if necessary, to improve communication confidence.
School and Family Interventions
Selective autism treatment is most effective as a coordinated effort among family, caregivers, teachers, and healthcare providers. The three pillars of these interventions include parent training, school accommodations, and positive reinforcement. Parent training equips caregivers with tools to reduce pressure around speaking, manage their anxiety, and reinforce progress at home. School accommodations such as reducing performance pressure and offering a safe space or trusted adult for support are essential to treatment. Positive reinforcement helps build confidence by celebrating small steps toward communication, providing a sense of safety and control.
Medication Options
In severe cases, medications, such as selective-serotonin reuptake inhibitors (SSRIs), may be helpful. However, this is typically only recommended when behavioral or speech therapy is not effective on its own.
Selective Mutism vs Other Conditions
Shyness vs Selective Mutism
Selective mutism should not be confused with shyness, as the former is a mental health disorder and the latter is a personality trait. Being shy involves a tendency to withdraw from people, especially strangers. However, shyness does not interfere with one’s daily functioning at the level, if at all, that a mental health disorder does. Almost everyone is shy to some degree, but it does not result in a physical inability to speak.
Selective Mutism and Autism Spectrum Disorder
Selective mutism and autism spectrum disorder are often co-occurring, as autistic individuals are more likely to have selective mutism. However, the two conditions are different, and experts group them into separate categories.
When to Seek Professional Help
Early intervention is essential for managing and treating mental health disorders. When a child speaks comfortably at home but struggles consistently with speaking in specific settings, such as school, social situations, or around unfamiliar people, consider consulting a mental health professional. Selective mutism can impact academic performance, social development, and self-esteem if left untreated. A qualified mental health provider can help create a tailored treatment plan and provide guidance to families and educators to support the child’s progress.
About KidsCare Home Health
KidsCare Home Health is a pediatric home health agency dedicated to serving children with special needs, including those with mental health disorders. With services conveniently available nationwide, we focus on nursing, speech therapy, physical therapy, and occupational therapy, as well as provide case management for children up to 18 years old.
Frequently Asked Questions about Selective Mutism
What causes selective mutism?
There is no specific cause for selective mutism. Research suggests that some conditions may contribute to a higher risk, such as bilingualism, decreased threshold of excitability in the amygdala, or expressive/receptive language and communication disorders.
Is selective mutism a disability?
Yes, it is a mental health disability, as it can severely interfere with one’s ability to navigate specific social settings.
Can children outgrow selective mutism?
Children can overcome selective mutism with the proper treatment, care, and support.
How long does treatment take?
The duration of selective mutism treatment depends on several factors: the child’s age, how long the mutism has been present, the severity of the anxiety, and the consistency of support at home and school.
Can selective mutism be cured?
The word “cure” isn’t typically used in clinical settings, as selective mutism is not a disease. As an anxiety-based condition, selective mutism can be effectively treated. Many children do fully overcome it, especially with early, consistent intervention.
