Silent Childhood Anxiety: Selective Mutism

Selective Mutism: What Does It Mean?

Selective mutism is a childhood anxiety disorder that causes a child to be unable to speak in certain situations. It is usually social settings, such as school, in which a child cannot communicate. It’s usually a result of severe anxiety or shyness.

For some selectively mute children, they are unable to communicate at all in social settings. Others may whisper or only be able to talk to particular people.

Definition of “Selective”

Selective means to affect some things but not others. In the case of selective mutism, this means that it is only particular settings that cause a child not to speak, rather than a total inability to speak. In all other settings, the child will be able to communicate.

The use of the word ‘selective’ does not mean that the child has the ability to select to speak or not speak, nor which settings to do so in. It is a much more complex process and the child is not intentionally choosing their behaviors.

Stubborn or Sick?

It is due to the selective nature of this disorder that selective mutism has been misinterpreted as stubbornness. The condition has often been misinterpreted by teachers and parents because the child has spoken at home but not at school or vice versa. This has lead to the adult believing that the child is purposely being ‘difficult’ or ‘defiant’.

Although in recent years there have been several studies in selective mutism, information is still lacking compared to other childhood disorders. A lack of information often means a lack of awareness and this is probably the true cause behind the misunderstanding of selective mutism symptoms.

Stats: How Many Suffer from this Disorder?

Studies suggest that selective mutism is a relatively rare condition, affecting between 0.47 to 0.76 of the population. Some studies indicate that it is slightly more common in females than males, although this is disputed by other studies so it’s not completely clear which are correct.

Children are normally diagnosed with the condition between the ages of five and eight, although symptoms usually begin earlier, as young as three years old.

Of children who are being treated in behavioral health settings, 1% have selective mutism. A 2005 study found that selective mutism was more prevalent in immigrant children and children who are in the language-minority of the area.

What Causes Selective Mutism?

The causes of selective mutism are not 100% agreed upon in the scientific community. In fact, they are frequently disputed and research results can often be contradictory. However, the following causes outlined are the most widely accepted reasons at present.

Suffering from severe anxiety or a social phobia is extremely common in children later diagnosed with selective mutism. In fact, over 90% of children with selective mutism also have social anxiety or a social phobia.

A genetic disposition to anxiety has been found in the majority of children diagnosed with selective mutism. In other words, one or more close family member of the child will have a tendency to be anxious. Of these children, the symptoms of severe anxiety are usually present from infancy: shyness, sleeping difficulties, separation anxiety etc.

There may be an environmental link to developing the disorder. Some research has found that children with reduced opportunities for social contact or who have had avoidance behaviors reinforced are more likely to develop anxiety related speech problems.

Shyness or having a timid nature has been linked to children with the disorder, although this is often disputed.

There is no evidence that selective mutism is caused by experiencing a trauma or suffering from abuse or neglect.

There is not one single cause identified for selective mutism and research seems to point towards causes being multifactorial rather than by a singular factor.

Signs and Symptoms of Selective Mutism

What are the Common Behaviors/Characteristics?

Aside from the inability to speak in particular settings, Selective Mutism Center lists the following symptoms as the most common characteristics:

Temperamental Inhibition: A tendency to be shy and timid in new and unfamiliar situations. The child will often have had separation anxiety from infancy.

Social anxiety: Being extremely uncomfortable in any social situations, including meeting new people, having any attention brought upon them in a group setting, or being teased. The child may be scared to eat in front of other people or may urinate due to their fear.

Social Being: Children with this disorder do still have a normal need for socializing and having friends, despite their condition. They may have several close friends that they can communicate with, either in a group setting or in one-to-ones.

Physical symptoms: Some of the physical symptoms associated with selective mutism include headaches, vomiting and shortness of breath. They may experience feelings of anxiety and fear and therefore all the associated physical symptoms of these feelings.

Appearance and body language: A child with selective mutism can often appear ‘frozen’ in body language. They can be expressionless and their body stiff. This is especially true for younger children with selective mutism as often the ‘frozen’ body language will lessen with age or be less present in an older child who develops selective mutism.

Emotions: A younger child with selective mutism will often not show any signs of being upset at their condition, perhaps because of a lack of self-awareness and also that younger children are more accepting/ unaware of social differences. An older child with the condition may become upset at their condition.

Other emotional behaviors displayed may include frequent tantrums, mood swings, being withdrawn and acting out.

Developmental Delays: Some children with selective mutism also have developmental delays in communication, motor skills and social development.

Sensory Processing Difficulties: There are some professionals who believe that a sensory processing disorder may be the underlying cause of selective mutism. They theorize that too much sensory input causes the child to ‘shut down’ which explains why the condition is so commonly present in busy settings such as the classroom.  Symptoms of sensory processing issues include covering eyes from bright lights, holding hands over ears to block out noise and being a very picky eater and sensitive to fabrics and touch.

In the classroom: Children with the condition will often seek out their own space in a classroom, staying away from the crowd. They will usually play alone or not at all. They may have difficulties in following instructions or staying focused.

Testing: What are the Diagnostic Criteria Per the DSM 5?

  • The child shows consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school), despite speaking in other situations.
  • The disturbance interferes with educational or occupational achievement or with social communication.
  • The duration of the disturbance is at least 1 month (not limited to the first month of school).
  • The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
  • The disturbance is not better explained by a communication disorder (e.g., child-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

Selective Mutism and Other Conditions

Selective Mutism vs Social Anxiety Disorder

Although the conditions can often be co-present, not all children with selective mutism will be diagnosed with social anxiety disorder.

Many children with social anxiety disorder will not display any of the symptoms of selective mutism or may only display some for a short period of time.

Likewise, although a child with selective mutism may show signs of anxiety, sometimes the anxiety will fade or completely go away whilst the selective mutism continues.

Social anxiety disorder is a complex condition and medical professionals will be careful to distinguish between the two when diagnosing.

Related Conditions

There are many other conditions associated with selective mutism and most are connected to anxiety and/or developmental or learning disabilities.

A child with the disorder will often also have co-existing conditions such as enuresis (urinating themselves), encopresis (soiling themselves), obsessive-compulsive disorder, depression, other language abnormalities, developmental delay, and Asperger’s disorders.

Panic disorders, social phobias, and extreme anxiety are often present.

Research suggests that nearly 40% of children diagnosed with selective mutism will also have experienced speech and language difficulties.

Selective Mutism In Adults/Children

Selective mutism is mostly a childhood disorder and is usually diagnosed in childhood years. However, if not treated properly or not diagnosed, the condition can continue on into adulthood.

It is believed that most children with the disorder develop coping mechanisms and methods that overcome the mutism symptoms. Even if the child grows up to suffer from a related disorder such as social phobia or anxiety disorder, often they will have learned to communicate sufficiently in social settings.

Example Case of Selective Mutism

Adopted from Selective Mutism Foundation testimonial by Dr. Wong in Selective Mutism: A Review of Etiology, Comorbidities, and Treatment:

“Chloe’s parents knew something was wrong when they were told by the four-year-old’s preschool teacher that she had spoken in school that day for the first time after attending preschool for almost eight months. When Chloe entered the classroom, she appeared hesitant and self-conscious and avoided eye contact. She would engage in an assigned task, but not with other children. Her comfort level dropped in a larger group, and she would not interact with the others in a group. If the other children talked to her, she would turn away.

She also did not speak in church or with distant family members, but she was a chatterbox at home. In elementary school, it was not until third grade that Chloe spoke to her teacher for the first time after a devoted teacher did behavioral therapy exercises with her in the summer and prior to and after school. Now in fourth grade, Chloe has made much progress and recently read a report on video. Chloe’s battle with this disorder is not completely over, but she has made tremendous progress.”

How to Deal/Coping With Selective Mutism

If a parent, teacher or guardian notices any signs or symptoms of selective mutism it is important to be proactive about seeking further advice. Avoid pressuring the child as this can worsen symptoms of anxiety and could reinforce the issues at hand.

For a child with selective mutism, there are

Look out for These Complications/Risk Factors

The main risk factors associated with this disorder is the development of similar anxiety disorders and further phobias. Treatment is necessary to avoid progression of the disorder into teenager years and adulthood.

A fear of speaking at school could affect a child’s education, either by lack of educational progress or through an avoidance of school altogether. A lack of social interaction could also have negative consequences, such as becoming withdrawn and lonely.

Selective mutism disorder could have an impact on a child’s self-esteem and confidence and this is an area that should be specifically worked on in treatment and in school.

Selective Mutism Treatment

Treatment for selective mutism will be an individually tailored program but there are certain therapeutic treatments are usually used: medication-based treatment and non-medication treatment. Early intervention is paramount to a full recovery so don’t hesitate to seek professional guidance.

Psychodynamic therapy, sometimes referred to as play therapy, is a popularly prescribed treatment. The reason why it’s particularly useful for this disorder is because it’s an extremely non-threatening approach and gives the child a lot of freedom.

Another common approach is the use of behavioral therapy. It usually includes using techniques such as reinforcements, non-verbal play and a slow, subtle introduction to social situations.

Medical professionals may also recommend family therapy, usually in conjunction with other therapies. There hasn’t been much research into the benefits of family therapy for this condition but it has proven effective for other similar conditions.

Possible Medications for Selective Mutism

Research is ongoing into medications for selective mutism but currently, selective serotonin reuptake inhibitors (SSRIs), particularly fluoxetine, have been shown to have some success.

Home Remedies to help Selective Mutism

There isn’t a particular home remedy recommended for selective mutism. Instead, families should closely follow the advice of a mental health professional which will often include suggestions of methods that the family can use at home.

Living with Selective Mutism

For the child with selective mutism, life can be really scary. Going to school, visiting family or going to a playground are all common activities that may trigger their condition. As a result, they may develop severe fears of these places.

A child may also be very frustrated by the condition and/or develop very low confidence. Childhood should be a time of playing, joy and happiness so it’s important to get help quickly so the child can recover.

Insurance Coverage for Selective Mutism

Your insurance provider should have a policy for childhood mental health conditions such as selective mutism. Every insurance provider is different so it’s recommended to contact yours directly and request full information on their policies.

How to Find a Therapist

What Should I be Looking for in an LMHP?

When searching for a LMHP, it’s a good idea to do some research first. Search for the state’s laws on accreditation and make a note of the qualifications you should be looking for. Remember to specify in your search that it’s for a child. You can also the Psychology Today website to find recommended therapists (link below)

You can also ask your physician for a few recommendations but don’t feel pressured if you don’t want to use any of their services.

Questions to Ask a Potential Therapist

Ask a therapist if they have ever worked with a child with selective mutism or an anxiety disorder. Check what treatment they would normally use and why. Ask for their success rate/average treatment time length.

Request references from previous families who have undergone similar treatment. You may also find references online with a means to contacting the referee.

Selective Mutism Resources and Support Helpline

Crisis Text Line: Text 741741

Selective Mutism Foundation:

Help With Talking:

Selective Mutism:

author avatar
Angel Rivera
I am a Bilingual (Spanish) Psychiatrist with a mixture of strong clinical skills including Emergency Psychiatry, Consultation Liaison, Forensic Psychiatry, Telepsychiatry and Geriatric Psychiatry training in treatment of the elderly. I have training in EMR records thus very comfortable in working with computers. I served the difficult to treat patients in challenging environments in outpatient and inpatient settings
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