Breaking the Silence: Selective Mutism

She walks through the halls with her dad, skipping, laughing, and talking about her day. Little does she know that I’m standing behind the door, soaking in the joy of their conversation. As I open the door to greet her, little Samantha freezes, buries her head in her dad’s jacket, and ceases to talk, laugh, or even smile…

Samantha is a pseudonym that represents a compilation of children that I see who experience an anxiety disorder called Selective Mutism (SM). SM is a relatively rare anxiety disorder (mostly occurring in childhood) that affects approximately .03-1.9% of the population, depending on the situation and setting. It was was once referred to as “voluntary aphasia” or “elective mutism,” suggesting that children were unwilling to speak or electing not to speak, but the reality of this disorder is that people with selective mutism often feel no choice in the matter.

How do I know if a child, teen, or adult has SM?

It is the persistent inability to speak in certain situations (usually school), despite being able to speak in other situations (usually home). This lack of speech is going to get in the way of living life day-to-day by interfering with education systems, jobs, or social communication in general. If this persists for more than one month (excluding the very first month of school), there is a chance that SM is the cause of the communication difficulties. If the person were to have a communication disorder (stuttering, apraxia, dyspraxia, articulation concerns) that would better explain the lack of speech, it would not be considered SM, but would need additional evaluation by a professional. In some cases, people who are bi-lingual or acquiring a second language will undergo a “silent period,” which is normal. SM would not be included within the typical range of that silent period. SM could be said to be an extreme fear of speaking.

What does it look like?

The onset of SM is often between ages 2-4, with a long period (usually 3-5 years) of delay of treatment. It is often misidentified as autism at early childhood screenings because some of the symptoms can overlap and look very similar. The difference is that SM will not be pervasive across all settings. People with SM can also have behavioral inhibition, which means that they have a hard time engaging non-verbally as well. These individuals express the feeling of “freezing” up. In children, we see the inability to hand or take things from people, engage in age-appropriate activities (high fives, dancing, gym class, etc.), and sometimes may not be able to physically enter spaces that create anxiety.

The good news!

SM is highly treatable with evidence-based interventions specific to the disorder. The “gold standard” for anxiety disorders is cognitive behavioral therapy or CBT. Since SM is specific to speaking and is often co-occurring with social anxiety, treatment also involves exposures, working toward a goal from an increasingly difficult hierarchy of activities. Translated, that means that people will work from non-verbal communication to verbal communication in small and manageable steps with support. For young children and families, parent child interactive therapy (PCIT) has been adapted specifically for this population. PCIT-SM has empirically based studies and is used across the country by individuals and centers to provide support in building brave muscles to speak. For older children with more engrained inability to speak, the SPACE (supportive parenting for anxious childhood emotions) has been studied in children with anxiety disorder and OCD and has been found to be incredibly effective.

…Samantha gives me a high five and says “Out the door, dinosaur,” as she leaves my office. She is working on talking back to her worry monster this week with 5 goals to use her brave voice outside of my office. As she comes up with ideas to quiet the worry monster’s voice, I look up at my wall to a quote that reminds me of how brave each and every individual is that enters my space.

Courage does not always roar. Sometimes Courage is the quiet voice at the end of the day saying, “I will try again tomorrow.”

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5®).

Bergman, R. L., Gonzalez, A., Piacentini, J., & Keller, M. L. (2013). Integrated Behavior Therapy for Selective Mutism: a randomized controlled pilot study. Behaviour research and therapy, 51(10), 680–689. https://doi.org/10.1016/j.brat.2013.07.003

Muris, P., & Ollendick, T. H. (2021). Current Challenges in the Diagnosis and Management of Selective Mutism in Children. Psychology research and behavior management, 14, 159–167. https://doi.org/10.2147/PRBM.S274538

Rodrigues Pereira, C., Ensink, J. B. M., Güldner, M. G., Lindauer, R. J. L., De Jonge, M. V., & Utens, E. M. W. J. (2023). Diagnosing selective mutism: a critical review of measures for clinical practice and research. European child & adolescent psychiatry, 32(10), 1821–1839. https://doi.org/10.1007/s00787-021-01907-2