Selective Mutism: Symptoms, Signs & Treatments

What Is Selective Mutism?

Selective mutism is an anxiety disorder in which a person is unable to speak or otherwise communicate in certain social situations. Many children with selective mutism might be talkative at home, but be unable to talk at school, daycare, or in other community settings. This disorder is usually first diagnosed in early childhood, and if left untreated, can lead to social anxiety, isolation, academic performance problems, and low self-confidence.¹

How Common Is It?

Selective mutism affects .03-1% of the general population, and the onset is usually before age 5, although many times it isn’t properly identified until much later. Unfortunately, this is because a person’s mutism can be misinterpreted as “normative shyness,” delaying treatment.

Selective Mutism Vs. Traumatic Mutism

When a person is unable to speak following a traumatic event, this is known as traumatic mutism. Some people who experience traumatic mutism might find themselves unable to speak when faced with the person who hurt them, or in a situation similar to the traumatic event they experienced. Trauma-focused interventions can be effective in supporting a person with traumatic mutism.

Selective Mutism Vs. Social Anxiety

Research shows that up to 80% of children with selective mutism have a comorbid anxiety disorder, most often social anxiety.¹
While many people have both selective mutism and social anxiety, there are some key differences. Those with social anxiety, for example, often avoid social situations altogether, and experience intense fears about engaging with others. This may manifest in somatic symptoms like shaking, sweating, increased pulse, or nausea, which are absent for people with selective mutism. People with selective mutism may not experience these identifiable worries, but instead find themselves unable to speak when around certain people or social groups.

Selective Mutism Symptoms

When people with selective mutism feel expected to speak, they become terrified. Their level of anxiety significantly increases, but by remaining silent or motionless, their anxiety level slightly decreases, obtaining temporary relief for themselves. This is an ineffective coping strategy, as their relief is only temporary—over time, these people become more anxious and suffer in silence if not treated effectively.

Symptoms of selective mutism can include:

• Consistent failure to speak in social situations where there is an expectation to speak, despite speaking in other situations (such as home)
• Does not initiate speech or reciprocally respond
• May grunt, point, or write to communicate
• Fear of social embarrassment
• Social isolation, withdrawal, cessation of play
• Clinging, shrinking, averting eye contact
• Compulsive traits
• Struggles to eat in front of others (not due to an eating disorder)
• Struggles to use a public restroom
• Negative affect
• Temper tantrums
• Mild oppositional behavior (due to anxiety, not an oppositional disorder)
• Symptoms interfere with educational, occupational, or social success
• Symptoms must last for one consecutive month
• Symptoms aren’t due to a lack of knowledge of the language

Signs of Selective Mutism

People with selective mutism usually speak at home, but symptoms can be so severe that they may not even be verbal in their own home with their parents or siblings (aka: “comfortable people”) if guests stop by the house, even if the guests are in another room. People with selective mutism may also struggle to speak to their “comfortable people” in community settings, such as at a restaurant, even if they’re in a more secluded booth far away from other families.

These people fail to initiate speech or reciprocate verbally in environments where speaking is expected, such as ordering at a restaurant or asking a store clerk how much something costs. This struggle to speak is despite the fact that they can speak and want to be able to speak with others. Wanting to speak, but being unable to speak, does not equate to defiant, oppositional, manipulative, or controlling behavior; it is anxiety. 

Ironically, some people with selective mutism actually are eager to engage in social situations in nonverbal manners, such as:

• Obtaining a non-speaking role in the school musical
• Playing a nonverbal card game with peers during indoor recess
• Pushing a peer on the swing at recess

These particular people with selective mutism are much more able to communicate nonverbally by pointing, nodding, shaking their head, and writing than people who are more frozen.

Does Selective Mutism Go Away On Its Own?

The DSM-5 confirms that, as many people with selective mutism age, they don’t always end up meeting the full criteria anymore. However, they usually still meet the criteria for social anxiety disorder, which is still clinically significant and can still negatively impact their lives in social, academic, and occupational settings.

Selective Mutism Example

Hailey’s father walked into her preschool classroom, waved to her and said, “Hi!” but she looked at him like a deer in headlights. He took her over to her favorite area of the classroom, the dramatic play area, to help her feel comfortable. Nobody else was around, and he tried again—he whispered this time, “Hi, Hailey.” Instead of acknowledging him, she looked blank, expressionless, and dead on the inside. He wanted to let her know it was him, and let her know that she was safe. 

A few minutes later, the children sat down for circle time. Hailey was seated in the circle next to the teacher’s left side. The teacher started the “circle-time” question on the right side, so as an intervention, Hailey would go last and could mimic something she heard. “What animal do you like best?” was the question. Every child answered the question. When it was Hailey’s turn, her body shrunk down, she averted eye contact and looked at the ground. Her dad couldn’t even tell if she was breathing. “Dogs,” he thought. “You like dogs. Just say it. It’s safe here. Dogs. Please,” he pleaded in his mind.

The teacher gave ample wait-time and then offered a forced-choice question: “Hailey, do you like cats or dogs better?” Instead of taking this chance, she nodded while still looking at the ground. Her dad let out his breath he didn’t even know he was holding. This is selective mutism and not shyness.

Selective Mutism Causes

The multifaceted origination of anxiety disorders and/or maintenance of anxiety disorders comes from a combination of:

• Genetics affecting brain chemicals/brain structure
• Personality/temperament
• Environmental factors
• Learned behavior

Because all of these issues above are intertwined, they can all have an effect on each other, which makes selective mutism so complicated.

Genetics and the Brain

Evidence shows that genes influence brain chemicals and alter brain structure, which then can lead to anxiety disorders. In addition, chronic and excessive anxiety actually changes the structure of different sections of the brain, perpetuating more anxiety.

There are many different anxiety disorders, and they can be passed down genetically without being the same exact anxiety disorder. The National Institute of Mental Health (NIMH) states, “vulnerability markers are now conceptualized as tied to families of anxiety disorders, as opposed to specific conditions.”⁵

Personality/Temperament

According to the DSM-5, there actually are specific temperamental and personality characteristics that are linked to a higher risk for developing anxiety.

Personality traits that can have a higher risk for anxiety include:

• Concepts such as negative affectivity
• Harm avoidance
• Behavioral inhibition

Environmental Factors

There are some environmental factors to take into consideration with selective mutism, including:

• Medical issues the first year of life
• Speech delays and/or hearing impairment
• English as a second language
• Parenting behaviors and styles

Learned Behavior

Selective mutism can also originate from learned behavior, such as a parent who models social inhibition, or having overprotective parents. A child may learn to be fearful or overly cautious of novel experiences from observing a parent’s response to these types of situations. However, this is actually a rare cause of selective mutism, but in combination with other factors, it can be one piece of the puzzle.

Complications of Selective Mutism

When selective mutism goes untreated, a person can experience severe low self-esteem, social anxiety, isolation, and academic or work problems. When diagnosed in childhood, selective mutism can persist into adolescence and adulthood when left untreated. When treated early, many children are able to overcome selective mutism. The longer it goes untreated, the more challenging it will be to treat.⁶

If a Parent Suspects Their Child Has Selective Mutism, What Should They Do?

If a parent notices signs of selective mutism in their child, it is important to seek professional help. The earlier a child receives treatment for selective mutism, the more likely they will be able to overcome it as they get older. Parents would benefit from seeking information to educate themselves on selective mutism. Accepting your child for who they are is always beneficial, and with selective mutism specifically, giving your child grace in moments when they cannot speak helps them feel supported. Encourage your child when they do attempt to communicate in challenging situations, and affirm their efforts along the way.

Establishing support systems in other areas of your child’s life is also helpful. Finding kind, nonjudgmental friends to spend time with can offer valuable social exposure that is nurturing and accepting. Contact your child’s school to request an IEP or 504 plan to make sure they receive any accommodations necessary to support them at school.

How Is Selective Mutism Diagnosed?

Selective mutism is diagnosed by a speech-language pathologist (SLP). This diagnosis is made primarily based on the client’s history, provided through interviews with parents, caregivers, and teachers. Oftentimes a child’s pediatrician will also be involved, along with a therapist, school counselor, or other professionals on the child’s care team.

Other things SLPs will assess during the process include your child’s hearing, their receptive language, the way their lips, tongue, and jaw move, and observing how your child speaks and communicates nonverbally in their interactions with the SLP.⁷

Selective Mutism Treatment

There are many treatment modalities that, when used in combination, can have great success (but cannot guarantee the total absence of symptoms).

Parent-Child Interaction Therapy (PCIT)

PCIT was built from multiple theories of development including attachment, parenting styles, and social learning. PCIT incorporates the concepts of child-directed interaction (CDI) and PRIDE skills (labeled praise, reflect, imitate, describe, and enjoyment), both at school and in community settings. Just because the word “parent” is in the title, doesn’t mean this can’t and shouldn’t be used in a variety of settings.

PCIT is meant to help a person feel:

• Valued
• Accepted
• Appreciated
• Worthy
• Confident

If a person with an anxiety disorder feels those positive feelings above, those alone can help reduce anxiety, and they will be more likely to speak.

Operant Conditioning

Operant conditioning involves gradual exposure to the feared stimuli (in this case, speaking), to shape behaviors, with successive approximations, to habituate and desensitize to anxiety. People with selective mutism are tasked with small challenges first, then positively reinforced for meeting those challenges. Then their challenges are gradually increased, which helps their brain continue to habituate and desensitize to anxiety.

Cognitive Behavior Therapy (CBT)

CBT for anxiety is based on a cognitive theory of psychopathology in which people’s thoughts or perceptions regarding situations in their lives can positively or negatively influence their emotional, physiological, and behavioral reactions.

In terms of selective mutism, people experience:

• Thought distortions
• Automatic negative thoughts (ANTS)
• Invalid rules and assumptions
• Exaggeration of the threat of danger
• Ignoring information that can contradict inaccurate beliefs
• Overgeneralization of situations
• Schema-driven behavior
• Catastrophizing
• Perseverating thoughts

These ineffective thought patterns that maintain anxiety need to be challenged in CBT therapy, which is most effective for people ages 7 and older, due to its abstract nature.

Mindfulness

Mindfulness is a specific therapeutic technique that can physically alter the amygdala in a beneficial manner, leading to less severe stress responses. This means that a person’s external stressors may remain the same, but the person does not feel as stressed-out by the stressors. When the brain physically changes, anxiety lessens.

Mindfulness combines:

• Deep breathing
• Sensory input
• Acceptance and serenity while in the present moment (otherwise known as the “here and now”)
• Non-judgmental awareness of present experiences

Intensive Treatment

Many times, a foundation of intensive treatment for selective mutism is beneficial in getting a “head-start.” Intensive treatment is typically 30 hours in a week with clinicians specializing in selective mutism. The skills practiced during the 30 hours of intensive treatment seem to hold their gains better than they do when practiced for an hour per week in traditional therapy.

Imagine gaining a 29-week “head-start” and saving 29 weeks of a person’s life. Multiple intensive treatment centers exist across the country, many of which are based on a “day camp” model running roughly six hours per day for one week at a time. The child is typically placed with a group of children based on age level, and each child has a one-on-one clinician.

Once the foundation of these skills has been built in an intensive program, the skills can be generalized into the child’s school environment and social situations within the community.

Handover/Takeover™ Exercises

Dr. Shipon-Blum, owner of the Selective Mutism Anxiety and Treatment Center in Pennsylvania, coined the term handover/takeover.™ These are exercises to practice appropriate nonverbal socialization and eye contact, but without directly letting the child know that is what is being practiced. Handover/takeover™ involves handing items to others and receiving items from others.⁹

Dr. Shipon-Blum gives an example of having a play-date over and doing a guided cooking project:

The parent of the child with SM can facilitate handover/takeover™ with a baking activity like this at a play-date: “Brayden, please pass Mikey the cinnamon.” A few seconds later, “Next is the vanilla. Mikey, the vanilla is near you. Please pass Brayden the vanilla so he can add it to his bowl.”

With selective mutism, the goal is first to practice looking toward someone, rather than practicing actual eye contact, but do not say, “Let’s practice looking toward Brayden,” since that will likely increase anxiety in a child with SM. Rather, prompt the handover/takeover™ exercises, and then looking toward someone will naturally come in time.

Reproducible Tasks

“Reproducible tasks” are tasks that are the same over and over again. When a child both enjoys an activity and feels competent with it, the thoughts and feelings that are produced regarding this activity boost the child’s confidence level.⁹ When a child’s confidence is up, their anxiety level is down. When a child’s anxiety level is down, their speech output is up.

Forced Choice Questions, Behavioral Descriptions, and Reflection

Someone with selective mutism has a better chance at being successful with forced-choice questions. A forced-choice question offers 2 or 3 choices. For example: “Do you want to play outside or inside?” The person with selective mutism may point outside. The other person responds with a behavioral description: “I see you pointing outside. Thank you for letting me know…Do you want to ride bikes, draw with chalk, or do something different?” The person with selective mutism may point to the basketball. The other person responds with a behavioral description: “I see you pointing to the basketball. Thank you for letting me know. Let’s play basketball!”

If the person with SM is farther along in treatment, it may look something like this: “Do you want to play outside or inside?” The person with selective mutism responds, “Outside.” The other person responds: “Outside. Thank you for telling me…Do you want to ride bikes, draw with chalk, or do something different?” The person with selective mutism responds, “Something different, basketball.” The other person responds by reflecting, “Something different. Let’s play basketball. Thank you for telling me.”

School Services

Most children with selective mutism will remain in their general education environment with typically developing peers, which is usually for the best. However, they can still obtain special-education services to help them succeed, such as counseling/social work, in addition to resource services and accommodations and antecedent management in the classroom to help reduce their anxiety and increase verbal output.

It is recommended to solidify special-education services for a child with SM under a 504 Plan or with an Individualized Education Plan (IEP) under the “other health impairment” (OHI) or “emotional disorder” (ED) category.

Some accommodations for selective mutism could include:

• Process time/wait time
• Forced-choice questions
• Coping activities during transitional periods
• Pointing/hand signals as acceptable on assessments
• Successive approximations to shape behavior
• Preferential seating near comfortable peers
• Behavioral descriptions
• Frequent breaks
• Movement breaks
• Handover/Takeover™ exercises
• Reproducible tasks
• Fidget manipulatives
• Proprioceptive and vestibular input opportunities
• Teacher to read presentations aloud for the student (that the student wrote)
• Assign the student non-speaking classroom oriented chores to help them feel important, needed, and successful
• Token economy system
• Private feedback on academic performance
• Bathroom card

Medication for Selective Mutism

Currently, there are no FDA approved medications specifically for selective mutism, but there are plenty of approved medications for anxiety disorders. There are several SSRI medications to choose from, and Prozac seems to be the most commonly prescribed for selective mutism. According to the Mayo Clinic, SSRIs are among the safest drugs because they are not habit forming and have low risk for side effects.¹⁰

A combination of CBT psychotherapy and medication (SSRI) shows the best outcomes for a variety of anxiety disorders.

How to Help Your Child With Selective Mutism

When a child is diagnosed with selective mutism, it can be hard for parents to know how to help. Here are a few ways you can support your child with selective mutism:

• Understand that your child’s inability to speak at times is not defiance and should never be punished. Trying to get your child to speak by offering rewards will also only serve to discourage your child.
• Affirm your child’s efforts and take the pressure off their ability to speak in triggering situations.
• Pause to give your child extra time to speak.
• Hold criticism and know that your child is doing the best they can in this moment.
• Take your child to treatment sessions regularly and ask your child’s care team how you can best support their progress at home.
• When your child talks, listen with presence and compassion.

Final Thoughts

Selective mutism is one of the most misunderstood mental health conditions. It is important that the sooner a person with selective mutism is recognized correctly, the sooner they can get treatment, and the sooner they get treatment, the quality of their life can improve.