Selective Mutism

Screening

Screening for selective mutism is conducted whenever selective mutism is suspected or as part of a comprehensive speech and language evaluation for any child with communication concerns. If a parent or caregiver reports that a child is communicating successfully at home but not in one or more settings, the SLP may want to consider the diagnosis of selective mutism.

Screening typically includes

Comprehensive Assessment

Please see ASHA's resource, Assessment Tools, Techniques, and Data Sources, for information on the elements of a comprehensive assessment, considerations, and best practices. Information specific to these practices in the comprehensive assessment of individuals with selective mutism is discussed below.

Evaluation and assessment of children with selective mutism is accomplished through a collaborative approach with an interdisciplinary team consisting of a pediatrician, psychologist or psychiatrist, SLP, teacher, school social worker or guidance counselor, and family/caregivers. During the evaluation, parents/caregivers may need to help elicit verbal output. The SLP can also involve parents/caregivers by requesting a video recording of the child's communicative behavior at home and then compare the child's behavior in a clinical or school setting. Video recordings may also be used for subsequent language sample analysis.

Several techniques can be used throughout assessment to reduce stress on the child, increase participation, and improve the quality of assessment findings. See "Meeting the Child" section for more details.

Case History

A diagnostic interview with parents/caregivers and teachers is conducted without the child present to help gather information about:

  • Any suspected problems (e.g., schizophrenia, autism spectrum disorder)
  • Environmental factors (e.g., amount of language stimulation)
  • The child's amount and location of verbal expression:
    • Who does the child talk to?
    • In what circumstances is the child most likely to talk?
    • Where/what settings is the child able to speak?
    • How does the child communicate—gestures? writing? sounds? whispering? short responses? (Kotrba, 2015)
  • The child's symptom history (e.g., onset and behavior)
  • Family history (e.g., psychiatric, personality, and/or physical problems)
  • Speech and language development (e.g., how well does the child express him/herself and understand others?)
  • Educational history review seeks information on academic reports, parent/caregiver and teacher comments, previous testing (e.g., psychological), and standardized testing

If the child is bilingual, the SLP will need to obtain the following information:

  • What languages does the child speak now? to whom?
  • How well does the child understand the different languages spoken to him/her?
  • Does the child speak in his/her first language successfully outside the home environment? If so, in what settings and with whom? (Johnson & Wintgens, 2001; Toppelberg et al., 2005)

Speech and Language Evaluation

The speech and language evaluation gathers as much information as possible on:

  • Language comprehension (e.g., standardized tests and informal observations)
  • Expressive language ability (e.g., video the child talking at home if the child does not speak with the SLP)
  • Nonverbal communication (e.g., pretend play, drawing) - see ASHA's Practice Portal page on Augmentative and Alternative Communication (AAC) 
  • Functional communication ability across various circumstances and settings (Fernald, 2014; Johnson & Wintgens, 2001; Kotrba, 2015; Selective Mutism Anxiety Research and Treatment Center & Shipon-Blum, 2012)
  • Oral–motor functioning, including strength, coordination, and range of motion of lips, jaw, and tongue (if the child allows)

It is possible that a child with selective mutism may not participate in formal evaluation activities; such nonparticipation may manifest as lack of oral responses and use of nonverbal responses (e.g. pointing or gesturing.) This in itself is diagnostic information regarding the child's response to social communication. If this occurs, the SLP can use supporting information to determine the child's best communication in private settings. This may include audio or video recordings from home, which offer more information than parent/caregiver descriptions. When there is a clear discrepancy between the child's communication at home and his/her communication in public, this may not yield scores for traditional standardized measures of speech and language but is suggestive of the overarching problem of difficulty with social language.

Speech Sound Production

Articulation, if it is able to be assessed, is typically normal in children with selective mutism. However, the presence of an articulation disorder may compound the anxiety of interacting with others (Anstendig, 1999). A comorbid phonological disorder was present in 42.6% of children in one study (Kristensen, 2000).

See ASHA's Practice Portal page on Speech Sound Disorders – Articulation and Phonology for more information related to speech assessment and treatment.

Voice

Some children with selective mutism have reported that their voice "sounds funny" (Dow, Sonies, Scheib, Moss, & Leonard, 1995). Voicing requires control and coordination of airflow and the vocal mechanism that may be disrupted by their level of anxiety and may present a challenge for an individual with selective mutism. Even in cases where a child verbalizes in front of the clinician, this speech may be produced in a whisper, at a decreased vocal intensity, or in an altered vocal quality. The SLP may document vocal quality at the time of the initial evaluation and then reassess during intervention. Often, the altered vocal quality lessens as anxiety decreases. Clinicians may also want to evaluate the level of vocal tension during the assessment.

Language Ability

Receptive language skills are typically at normal levels or above normal in children with selective mutism.

Individuals with selective mutism have demonstrated shorter, less detailed, and more linguistically simplistic narratives, despite having normal receptive language and nonverbal cognitive abilities (McInnes, Fung, Manassis, Fiksenbaum, & Tannock, 2004). Subtle deficits in expressive language may be present and are theorized to be exacerbated by lack of experience in the expressive language domain (Klein, Shipon-Blum, & Spillman-Kennedy, 2009).

See ASHA's Practice Portal page on Spoken Language Disorders for more information related to language assessment and treatment.

Cognitive Abilities

Cognitive and academic abilities are typically within normal limits in children with selective mutism (Dummit et al., 1997); however, it can be challenging to evaluate them reliably. Difficulty responding using verbal and nonverbal responses, avoidance of interacting with unfamiliar adults, and slowness to respond can lead to lower test scores and misinterpretation of the child's ability, without consideration of anxiety as a factor in performance (Kotrba, 2015).

Social Skills

Pragmatic skills typically appear impaired outside the home and other familiar environments and, at times, may appear impaired in the home as well. Research is not clear as to whether or not children with selective mutism have pragmatic language deficits beyond avoiding communicating in certain circumstances outside the home setting (McInnes et al., 2004). Social immaturity is not uncommon because the child with selective mutism has fewer social interactions and may lack social awareness (Kotrba, 2015). Children with selective mutism can display decreased nonverbal and verbal indicators of social engagement, such as proxemics, facial expressions, gestures, eye contact, turn taking, participation in joint activity routines, and joint attention (Hungerford, Edwards, & Iantosca, 2003). Home video samples are helpful in assessing social communication and variations across settings.

Please see ASHA's Practice Portal page on Social Communication Disorders in School-Age Children for more information related to assessment and treatment.

Assessment Considerations

Meeting the Child

The SLP can conduct a diagnostic interview with parents, caregivers and teachers to prepare for the initial meeting. Consider meeting the child one-on-one or with the parent/caregiver present prior to formal assessment. The clinician can reassure parents/caregivers that there are no expectations for the child to speak during the initial session. Ensure that there will be no interruptions and no one else is using the room in whatever setting you will be meeting (e.g., clinic, school, home) (Johnson & Wintgens, 2001).

Consider letting the child and parent/caregiver play in the assessment room for 5–10 minutes without the SLP in the room. If observation/videotaping is available, the SLP can observe. This allows for comparison of the child's communication with and without an unfamiliar person in the area. After this time period, the SLP can enter the room and allow the child and parent/caregiver to continue playing for several minutes. Then, enter the child's circle of play (Middendorf & Buringrud, 2009).

Be prepared to make the first sessions informal and flexible. Develop a relationship with the child prior to the evaluation by scheduling two to three sessions for age appropriate recreational or play-based interactions without the expectation for speech. Play at the child's level, and follow his/her lead with open-ended, creative play involving arts and crafts, building blocks, and/or board games (Kotrba, 2015).

The first meeting with the child is likely to affect the success and rate of progress that will be made throughout intervention, so avoid triggering the child's anxiety by using defocused communication strategies (Oerbeck, Stein, Wentzel-Larsen, Langsrud, & Kristensen, 2014), such as:

  • Minimizing eye contact. Sustaining eye contact from unfamiliar people can make children with selective mutism uncomfortable.
  • Using phrases and terms that enourage the child to communicate, including using the terms words or voice rather than talk or speak. The latter two words may have negative connotations for the child (Kotrba, 2015). Also, encourage the child to show, gesture, write, or draw if he/she does not want to speak (Schum, 2006).
  • Creating joint attention using an activity that the child enjoys.
  • Thinking aloud by providing behavioral descriptions of what the child is doing, rather than by asking direct questions (e.g., "I see that you're playing with the truck!" instead of "What are you doing?").
  • Allowing plenty of response time rather than talking for the child. Processing time is valuable for children with selective mutism.
  • Continuing the conversation, even when the child does not respond verbally.
  • Receiving the child's responses in a neutral way.
  • Maintaining a calm demeanor and environment.
  • Considering your seating arrangement. Some children may prefer that you sit by their side rather than face-to-face, whereas this may be too close for others.

Use of non-threatening tasks, such as a picture-pointing task, may be beneficial during assessment when selective mutism is suspected as a possible diagnosis. Acknowledge and respond to the child's gestures for expressive communication if the child is nonverbal. Assess the effectiveness of the child's attempts at nonverbal communication and the child's behaviors when engaged in communication. Be mindful of variabilities within nonverbal communicaton. See ASHA's Practice Portal pages on Cultural Competence and Social Communication Disorders in School-Age Children for further information.

Collaboration With Other Professionals and Referral

During evaluation and treatment, the SLP may collaborate with and refer to the following professionals:

  • Pediatrician
  • School or clinical psychologist/psychiatrist
  • Behavior analyst/behavioral specialist
  • Teacher
  • Social worker
  • Guidance counselor
  • Family
  • Extended family and/or caregivers

The SLP's role on the evaluation team is to identify and describe (a) the child's communication skills and coexisting communication disorders and (b) the their impact on the child's ability to consistently participate in various settings (Kotrba, 2015). If the SLP is the first professional that a family encounters, it may be important to provide referrals to behavioral health professionals with training and experience in working with children with anxiety disorders, behavioral therapy, cognitive therapy, and integrated treatment approaches that are broader than the speech-language scope. Staying in regular contact with the behavioral health professional of the individual with selective mutism is particularly important in optimizing outcomes and promoting generalization.

Differential Diagnosis

Consider whether a child's failure to speak is better accounted for by a communication disorder, schizophrenia, or other psychotic disorder (Kearney, 2010). "The main differential symptom between SM [selective mutism] and other anxiety disorders, developmental disorders, or language-based disorders is that the child with SM can talk in certain situations, but is not able to use that same quality/consistency/volume of speech in other situations due to anxiety" (Kotrba, 2015, p. 27). Interprofessional practice with a behavioral health care professional—such as a clinical psychologist, social worker, or psychiatrist—can aid the SLP in differential diagnosis.

SLPs also need to consider whether or not the child is immersed in a new language environment, as acquiring another language is a complex process. When children are first exposed to a second language, they can appear very quiet, speaking little as they focus on listening and comprehension. This is known as the silent period. Diagnosing selective mutism depends on understanding typical bilingual child development. Bilingual children with true selective mutism present with mutism in both languages, in several unfamiliar settings, and for significant periods of time (Toppelberg et al., 2005). Interviewing parents/caregivers to determine if the child speaks in his/her first language successfully outside of the home environment is important information for the SLP to gather to inform differential diagnosis.

If the SLP does not speak the language(s) of the child, it will be necessary to collaborate with an interpreter/translator. Be mindful of the number of people in the room and the introduction of an additional person. The SLP may need to consider asking a family member to act as an interpreter in this circumstance so as not to create additional anxiety or stress for the child. See Collaborating With Interpreters for more information.

Some children will not speak after a traumatic event or ongoing social–emotional difficulties, such as parental divorce. Children who do not speak as a result of trauma are mute in all settings (Manassis et al., 2003). If the child spoke well prior to these events, then a diagnosis of selective mutism is not seemingly appropriate. Instead, the child may require assistance in adjusting to the trauma or other life challenges (Kearney, 2010), in which case, referral to a behavioral health professional is appropriate.

Determining Educational Eligibility

Interprofessional practice (IPP) and family involvement are essential in assessing and diagnosing selective mutism; the SLP is a key member of a multidisciplinary team. In diagnosing selective mutism, it is important that clinical experts agree on assessment results being consistent with the diagnostic characteristics of the disorder.

There is no single preferred, consistent diagnostic category. However, within the public school setting, eligibility for special education services under the Individuals With Disabilities Education Act of 2004 (IDEA, 2004) could be determined to fall within the disability categories of Other Health Impairment, Speech-Language Impairment, or Emotional Disturbance/Disability. If the child does not qualify for an individualized education program (IEP), then consider whether a 504 plan would meet some of the child's needs in the classroom.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.