Selective mutism is a condition in which a person can speak in some situations but not in others. For example, a child with selective mutism may speak at home but not at preschool or around strangers.
Selective mutism is different than conditions that cause a physical or cognitive inability to speak. People with the condition are able to talk, but they find it difficult due to anxiety. For this reason, many doctors and advocacy groups define selective mutism as an anxiety disorder.
In this article, we look at selective mutism in more detail, including the signs, causes, diagnosis, and treatment.
Selective mutism is a rare condition that causes difficulty speaking in certain situations but not in others. Some refer to it as a phobia of talking.
People with selective mutism can be confident communicators in many contexts but then struggle in settings that are unfamiliar or public.
For example, in children, selective mutism
The average age of onset for selective mutism is 5 years, although this may be because this is the age at which many children begin going to school. Most studies suggest that selective mutism affects less than 1% of children. Sometimes, selective mutism persists into adulthood.
The condition appears to occur more often in females than in males, although the reasons for this are not clear. It is also more common in children who are immigrants or second-language learners.
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) states that to meet the criteria for selective mutism, a person must have:
- consistent difficulty speaking in situations where talking is expected, such as at school, despite having the ability to talk in other situations
- difficulty speaking that is not due to a lack of knowledge of or comfort with the language someone is speaking
- difficulty speaking that is more likely due to another condition, such as a communication disorder
- symptoms that last for at least 1 month and interfere with school, work, or socializing
For example, a person may speak only when at home or with a select group of people.
When a person with selective mutism is in a situation where they have difficulty speaking, they may use other means of communication. These could include:
- whispering
- writing things down
- making gestures, such as pointing
Selective mutism often occurs with symptoms of social anxiety. In adults, this condition may cause:
- extreme shyness
- avoiding conversation
- a lack of eye contact
- freezing when put on the spot
- anxiety about eating in public, using restrooms, or being in photos
In children, social anxiety may cause behaviors such as hiding or running away, clinging to parents or caregivers, crying, or having tantrums when someone asks them to speak.
Selective mutism is not the result of defiance or disobedience. Instead, people with selective mutism feel unable to speak due to intense anxiety and shyness. They may fear others judging, ridiculing, or ignoring them.
The condition has no single cause. Instead, many factors can contribute to someone developing selective mutism. These factors include:
- Significant transitions: Going to school can cause anxiety in children. This is especially true if they have had few opportunities to socialize before or they are second-language learners. Bilingual children are overrepresented in studies on selective mutism, which suggests that anxiety about communicating could contribute to the condition.
- Home environment: Children who observe anxious or avoidant behavior at home may learn to behave in a similar way. This may lead to them avoiding situations that make them nervous, such as social situations. This avoidance can, in turn, reinforce a fear of talking.
- Genetics: Selective mutism tends to run in families, and researchers have identified at least one gene that appears to elevate the chances of developing it.
- Other anxiety disorders: Having other anxiety disorders may play a role in the development of selective mutism. Some examples include separation anxiety, social anxiety, and obsessive-compulsive disorder.
The DSM-5 defines selective mutism as an anxiety disorder. It specifically notes that doctors should not diagnose selective mutism when another diagnosis, such as autism spectrum disorder (ASD), better explains the symptoms.
According to current diagnostic criteria, therefore, selective mutism and ASD cannot coexist.
This definition is controversial. Some researchers argue that selective mutism may be a symptom of ASD or a diagnosis that commonly occurs alongside ASD. For example, a 2018 study of 97 children with a selective mutism diagnosis found that
Whether selective mutism and ASD are related continues to be a subject of debate. However, parents and caregivers can seek expert help and advice from a knowledgeable pediatrician or mental health professional.
Diagnosing selective mutism involves a comprehensive assessment, which may involve:
- a speech and language evaluation
- interviews with parents, caregivers, or teachers
- collaboration with a variety of specialists, possibly including a pediatrician, child psychologist, behavior analyst, guidance counselor, or social worker
The speech and language evaluation can screen for any other conditions that might cause difficulty with speech, such as a speech delay or hearing impairment. Then, interviews with family members can help specialists get a sense of:
- when the symptoms began
- how the child currently communicates
- the home environment
- family medical history
Eventually, a speech-language pathologist (SLP) might wish to meet the child informally to observe their behavior. Minimizing stress is important at this stage, so the SLP will not put pressure on the child to talk.
Once a medical team has reached a diagnosis of selective mutism, treatment can begin. Although the treatment approach can vary, the goals center on:
- reducing anxiety in social settings
- helping the person practice speaking
- reinforcing nonavoidant behavior
The emphasis is on making the person with selective mutism feel safe but gradually more confident. Some examples of treatments for selective mutism include:
- Augmentative and alternative communication (AAL): AAL involves temporarily giving people an alternative way of communicating that they find less stressful. For example, a child may learn to use gestures or point to symbols. In the short term, this can help a child communicate at school, but it is not a long-term solution.
- Exposure-based therapies: These approaches involve gradual exposure to a situation that a person may find anxiety-inducing, so that they can practice speaking. Over time, this shows the person that they can speak in front of people.
- Ritual sound approach (RSA): This therapy involves an SLP helping a child learn to produce sounds from a mechanical perspective. They may start with nonspeech sounds, such as blowing or coughing, and work toward syllables and then words.
An SLP will tailor any therapy to the person’s symptoms, age, and other needs.
People with selective mutism also require support for their emotional health. Selective mutism can make it difficult for people to talk about their feelings, state what they need or want, and socialize with others.
Psychotherapy can help children and adults learn to manage the fear they feel about speaking. It can also help with any coexisting mental health conditions, such as social anxiety.
According to the National Health Service (NHS) in the United Kingdom, medication may help reduce the symptoms of anxiety or depression in teenagers and adults, but it should never be a replacement for behavioral therapies.
Selective mutism is an anxiety disorder, so putting pressure on someone to speak will only create more stress and fear. In fact, repeatedly encouraging a child to “talk” or “speak” may mean that they develop negative associations with those words over time.
Instead, people can help those with selective mutism by creating a safe space. It is also important neither to force people with the condition to interact if they do not want to nor to try to treat the condition at home. Selective mutism requires professional treatment.
People can help create a supportive environment for children with selective mutism by following the tips below:
- Positive reinforcement: It is important to praise the child when they try to communicate aloud, even when it is not perfect. However, this should be in a private setting to avoid causing embarrassment.
- Patience: It may take longer for a child with selective mutism to respond to questions. Try to be patient and give them time to choose their words, and encourage others to do the same.
- Environmental adjustments: It is important not to avoid all sources of stress when a child has selective mutism, as this can reinforce avoidance. However, changing the environment can help make things easier. For example, instead of avoiding family gatherings entirely, consider introducing children to family members individually and giving them time to feel comfortable around each person.
- Shared activities: If a child is finding it difficult to talk, try doing an enjoyable activity together instead. This can take the focus off of communication while still providing the opportunity to bond.
- Alternative communication: Children may need an alternative way of speaking during times when they feel stressed. This could involve using gestures, writing, or text messaging. Make sure the child knows that not being able to speak is not a failure and that it is okay to use other methods when they feel the need.
- Educating others: Ensure that other family members and teachers understand selective mutism and the accommodations it requires. For example, teachers may need to understand the child’s alternative method of communication so that they can ask to use the bathroom.
According to the Selective Mutism Foundation, it is often not beneficial to place children with this condition into special education. As selective mutism alone does not cause speech or language impairments or intellectual disability, the type of support that a special education setting can provide may not be useful.
With adaptations, many of the above strategies can help when interacting with teens and adults, too. Additional ways in which people can support adults with selective mutism include:
- educating oneself about selective mutism
- learning to use the person’s alternative method of communication so that they always have a way to talk
- providing school or workplace accommodations, if the person wants them
The U.K. advocacy group iSpeak provides a list of accommodations that workplaces can make for people with selective mutism.
Selective mutism is an anxiety disorder that affects communication. People with the condition find that they can talk in some situations but not in others. This behavior is an involuntary response to stress rather than a choice.
Treatment for selective mutism can involve behavioral therapies, psychotherapy, or both. Due to the impact that the condition has on people’s lives, it is important for family members, teachers, and peers to treat those with selective mutism with compassion and understanding.
