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Selective Mutism

What Is It, Symptoms, Treatment, and More

Author:Anna Hernández, MD

Editors:Alyssa Haag,Emily Miao, PharmD,Kelsey LaFayette, DNP, RN, FNP-C

Illustrator:Jessica Reynolds, MS

Copyeditor:Stacy M. Johnson, LMSW


What is selective mutism?

Selective mutism (SM) is a rare anxiety disorder where an individual cannot speak at school or other specific social situations but have no trouble speaking in different, presumably more comfortable settings. The condition typically affects children and is considered a childhood anxiety disorder, but can also affect older individuals. 

A child afraid to speak in a social situation.

What causes selective mutism?

The exact cause of selective mutism is currently unknown, but it is thought to be a combination of genetic and environmental factors. The onset of selective mutism usually occurs before the age of five. It is often accompanied by a social anxiety disorder or phobia, characterized by excessive anxiety towards social situations (e.g., meeting groups of new people, giving a speech, or going to social events), where individuals feel like others could negatively evaluate them. Individuals who have experienced neglect or abuse, have poor social or family relationships, or have speech or language problems, such as stuttering, are more likely to develop selective mutism.

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What are the signs and symptoms of selective mutism?

The main symptom of selective mutism is the individual’s failure to speak in specific settings, such as when meeting new people, despite having the ability to speak in other, presumably more comfortable situations. Instead of communicating verbally, individuals may communicate by gestures, nodding, head-shaking, or sometimes short monosyllabic words or whispering. In other cases, they may not communicate at all.

Children with selective mutism often experience a heightened sense of anxiety when there is an expectation to speak, such as when asked a question in front of their peers in class. The severity of selective mutism varies between individuals and may impact their ability to speak to extended family members, talk on the phone, speak to their teacher, or read aloud in a small group. In severe cases, individuals may attempt to avoid these situations, causing intense distress that significantly interferes with their daily routine, occupational or academic functioning, or social activities and relationships.

How is selective mutism diagnosed?

According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, or DSM-5, selective mutism is diagnosed when individuals persistently fail to speak in specific social situations but can speak freely in others. The failure to speak must last for at least one month, except for the first month of school, where hesitation to speak can be expected and may interfere with education or occupational attainment. To diagnose selective mutism, the failure to speak should not be attributable to a lack of knowledge or comfort with the spoken language or a communication disorder. 

Selective mutism is often diagnosed when the child first attends preschool or kindergarten. That is typically the first time children are expected to speak with someone other than their parents and family. In some cases, diagnosis may be delayed, as parents may believe the problem lies in the classroom, with the teacher or school climate, considering the child has no trouble speaking freely at home.

How is selective mutism treated?

Treatments for selective mutism typically include cognitive-behavioral therapy (CBT), play therapy, and family therapy. One cognitive-behavioral therapy strategy is stimulus fading, which involves creating a relaxed situation with someone familiar to the child can talk to and gradually bringing someone new into the room. Play therapy is a unique type of psychotherapy where play is used as a means of helping children express or communicate their feelings. Family therapy, however, can allow parents to be closely involved with the child’s therapy and work on ways to improve communication together. 

Additionally, there are several ways teachers can make communication less stressful at school. Examples include establishing a relaxed atmosphere in the classroom; encouraging and accepting all attempts at communication (e.g., with gestures, pictures, objects, whispering); providing quiet spaces for children to sit and talk together; speaking or singing in unison, and planning activities requiring single words or short answers. 

In cases with significant anxiety that interferes with daily activities, medications like selective serotonin reuptake inhibitors or SSRIs (e.g., fluoxetine, paroxetine, sertraline, citalopram) might be recommended in combination with psychotherapy. 

What are the most important facts to know about selective mutism?

Selective mutism is an anxiety disorder when individuals fail to speak in specific social situations, despite speaking in other, presumably more comfortable situations. To diagnose selective mutism, the failure to speak should be recurrent, last for at least one month, and interfere with the individual’s education or work. Treating selective mutism involves cognitive behavioral therapy, family or play therapy, parent-teacher interventions, and SSRIs.

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Related links

Childhood and early-onset psychological disorders: Pathology review
Phobias

Resources for research and reference

Forrester, C., & Sutton, C. (2015). Selective mutism in our own words: Experiences in childhood and adulthood. Jessica Kingsley.

Johnson, M., & Wintgens, A. (2012). Can I tell you about Selective Mutism?: A Guide for Friends, Family, and Professionals. Jessica Kingsley.

Johnson, M., & Wintgens, A. (2016). The selective mutism resource manual: 2Nd edition (2nd ed.). Speechmark Publishing.

Mulligan, C. A., & Shipon-Blum, E. (2015). Selective mutism: Identification of subtypes and implications for treatment. Journal of Education and Human Development, 4(1). https://doi.org/10.15640/jehd.v4n1a9