Selective Mutism (SM) Basics

A child with selective mutism (SM) speaks normally at home — and may even be a “chatterbox” — but is unable to speak in other social settings, such as school. This guide outlines the symptoms of selective mutism, how it is diagnosed and recommended treatments.

SM: What Is It?

Selective mutism (SM) is an anxiety disorder in which a child is unable to speak in some settings and to some people. A child with SM may talk normally at home, for instance, or when alone with her parents, but cannot speak at all, or speak above a whisper, in other social settings—at school, in public, or at extended family gatherings. Parents and teachers often think the child is willful and refuses to speak, orspeak loud enough to be heard, but the child experiences it as an inability. It can cause severe distress—she can’t communicate even if she is in pain, or, say, needs to use the bathroom—and prevents her from participating in school and other age-appropriate activities. It should not be confused with the reluctance to speak a child adapting to a new language might exhibit, or shyness in the first few weeks at a new school.

SM: What to Look For

If your child struggles with selective mutism, she may be freely verbal and even gregarious at home—“chatterbox” is a description professionals often hear—but completely or mostly nonverbal at school. Some children seem paralyzed with fear when they are unable to speak, and have difficulty communicating even non-verbally. Others will use gestures, facial expressions, and nodding to get by when they cannot speak. Even in the home, some will fall silent when someone other than a family member is present. Parents often notice signs of SM when a child is 3 or 4 years old, but she may not be diagnosed until she gets to school, and efforts to get her to speak up have failed.

SM: Risk Factors

Because of its overlap with social anxiety disorder, there may be genetic loading for SM. Other risk factors are temperamental (negative affectivity, behavioral inhibition) and environmental, including socially inhibited or overprotective parents.

SM: Diagnosis

Diagnosis should be made by a professional familiar with selective mutism who can rule out other conditions that present similar symptoms. Since young, anxious children have difficulty participating in interviews—particularly if they have SM—the expert making the diagnosis will rely heavily on reports from parents and other adults in the child’s life, to determine a pattern of behavior across situations. They might request home videos of the child’s behavior in her “place of strength” and/or observe her alone with her parents (though a one-way mirror). To be diagnosed with SM a child must be able to speak in some settings but not in others, the condition must have lasted for a month that is not the first month of school, and it must interfere with schooling and social activities.

SM: Treatment

Behavioral: The most evidence-based recommended treatment for selective mutism is behavioral therapy using controlled exposure. The therapist works with the child and her parents to gradually and systematically approach the settings where she cannot speak, building her confidence one situation at a time. The child is never pressured to speak, and is always encouraged with positive reinforcement. Specialized techniques are used to guide the child’s increasing exposure to difficult settings, and the therapist will teach parents and child how to use these techniques in real-life settings. Newer approaches offer evidence that intensive treatment from the time of diagnosis may prove more effective than traditional weekly sessions.

Pharmacological: Not every child with selective mutism requires medication. Some children may be prescribed anti-anxiety medications from the start, typically if their initial presentation is quite severe, if they’ve had SM for a long time, if they have not done well with a prior behavioral or other psychotherapy, if they have a very strong family history of similar disorders, or if they suffer from other impairing anxiety disorders as well as selective mutism. Some children will be prescribed medication if the results of an initial behavioral intervention fall short of the desired gains, or the process is too onerous. Many children who take medication as part of their treatment find that exposure tasks become easier to tolerate, making the difference between success and avoidance. The preferred medication for SM is one of the selective serotonin reuptake inhibitors, or SSRIs, better known as antidepressants. SSRIs are effective for anxiety and are tolerated well by children, who should always monitored for the presence of side effects.

SM: Risk For Other Disorders

Children with selective mutism tend to have a history of being socially very inhibited, and are also diagnosed with other anxiety disorders like social anxiety disorder, separation anxiety disorder, and specific phobias. Some kids with SM may appear to be oppositional when they’re pressured to speak. Children with SM may also struggle with mood disorders as well as learning disorders; those conditions should be addressed along with SM in the child’s treatment plan.