Selective mutism is a complex childhood anxiety disorder characterized by a child's inability to speak and communicate effectively in select social settings, such as school. An individual's pattern of mutism can vary greatly. Some children or adults never talk outside the home, some whisper, and some speak with only a select few people. The "individual has not elected to withhold the ability to talk in all situations; rather, the individual selects the situations and people with whom they verbally communicate" (Richard, 2011, p. 8). Children with selective mutism typically do not speak at school, which interferes with academic, educational, and/or social performance. Children with this disorder sometimes communicate via nonspoken or nonvocal means (e.g., pointing, writing).
Collaboration between the speech-language pathologist (SLP) and behavioral health professionals (such as a school or clinical psychologist, psychiatrist, or school social worker), as well as the classroom teacher and the child's family, is particularly important for appropriate assessment and treatment planning as well as implementation because selective mutism is categorized as an anxiety-based disorder. SLPs are in an excellent position to coordinate intervention for children who have selective mutism because of their knowledge and skills in effective communication treatments (Schum, 2002).
The incidence of selective mutism refers to the number of new cases identified in a specified time period. Prevalence is the number of individuals who are living with selective mutism in a given time period. Accurate population estimates of selective mutism have been difficult to ascertain due to the relative rarity of the condition, differences in sampled populations, variations in diagnostic procedures (e.g., chart review, standardized assessment), and the use of different diagnostic criteria (Busse & Downey, 2011; Sharkey & McNicholas, 2008; Viana, Beidel, & Rabian, 2009).
Selective mutism falls within the category of Anxiety Disorders (APA, 2013, pp. 195–197). According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013, p. 195), the diagnostic criteria for selective mutism are as follows:
These behaviors are a method of self-protection during an experience of intense anxiety but may appear deliberately oppositional (Kotrba, 2015).
Individuals with selective mutism may present with social anxiety and social phobia. Symptoms of social anxiety and social phobias may include the following:
(Beidel, Turner, & Morris, 1999; Kearney, 2010)
In addition to these features of social anxiety, children with selective mutism avoid initiating and participating in conversations. If they are able to express themselves, they may rely on gesturing, nodding, pointing, or whispering. They may have fears of being ignored, ridiculed, or harshly evaluated if they speak.
No single cause of selective mutism has been identified, and its causes seem to be multifactorial (Cohan, Price, & Stein, 2006). The following factors may coexist and play a role in selective mutism:
Appropriate roles for SLPs include but are not limited to:
As indicated in the Code of Ethics (ASHA, 2016), clinicians who serve this population should be specifically educated and appropriately trained to do so.
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
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.
A diagnostic interview with parents/caregivers and teachers is conducted without the child present to help gather information about:
If the child is bilingual, the SLP will need to obtain the following information:
The speech and language evaluation gathers as much information as possible on:
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.
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.
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.
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 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).
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 Disorder for more information related to assessment and treatment.
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:
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 Disorder for further information.
During evaluation and treatment, the SLP may collaborate with and refer to the following professionals:
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.
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.
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.
Early intervention for selective mutism is key to remediation. Continued difficulty speaking in certain situations and contexts strengthens this pattern. Consistency in the intervention and expectations, at home and at school, of everyone on the team involved is important when working with children with selective mutism. When providing predictability and control for the child with selective mutism, he/she will feel a decrease in anxiety and an improvement in self image based on mastery of skills in a variety of settings (Kotrba, 2015). The use of social stories and scripting can be helpful ways to reduce the child's anxiety and uncertainty in a variety of social situations (Dow et al., 1995; Kotrba, 2015).
The behavioral perspective views selective mutism as a learned behavior that the individual has developed as a coping mechanism for anxiety. The purpose of treatment is to decrease anxiety and increase verbal communication in a variety of settings, incorporating practice and reinforcement for speaking in subtle, nonthreatening ways (Cohan, Chavira, & Stein, 2006; Camposano, 2011; Kotrba, 2015). Reinforcements may be
Behavioral strategies may be incorporated into interventions for children with selective mutism across disciplines. These strategies include:
Exposure-based practice. This involves the child saying words in gradually but increasingly difficult or anxiety-provoking situations. Exposure-based practice aims to (a) replace anxious feelings/behaviors with more relaxed feelings and (b) increase the child's feelings of independence by gradually improving his/her ability to speak in different situations (Kearney, 2010; Middendorf & Buringrud, 2009).
Systematic desensitization. This involves the use of relaxation techniques along with gradual exposure to successively more anxiety-provoking situations (Cohan, Chavira, & Stein, 2006; Kearney, 2010).
Stimulus fading. This involves gradually increasing exposure to a fear-evoking stimulus (e.g., the number of people present or the presence of an unfamiliar person in the room while the child is speaking). This process usually includes rewarding the child when he/she is speaking in the presence of someone to whom he/she does not typically speak (Middendorf & Buringrud, 2009; Viana et al., 2009).
Contingency management, positive reinforcement, and shaping. This includes (a) providing positive reinforcement contingent upon verbalization and (b) reinforcing attempts and approximations to communicate (i.e., shaping) until such attempts are shaped into verbalizations, with the goal of making verbalizing more rewarding than not responding. Shaping is commonly used in combination with contingency management and positive reinforcement.
Augmentative and alternative communication (AAC) involves supplementing or replacing natural speech with aided symbols (e.g., pictures, line drawings, tangible objects, and writing) and/or unaided symbols (e.g., gestures). Some children who have been diagnosed with selective mutism may temporarily adapt an AAC system to facilitate classroom communication during initial stages of intervention. Use of AAC is not a long-term solution. AAC should be carefully monitored to ensure that it facilitates interaction rather than replaces verbal communication.
Please see ASHA's Practice Portal page on Augmentative and Alternative Communication for further information.
In augmented self-modeling, the individual watches a video segment or listens to an audio segment—one in which he/she is engaging in a positive verbal interaction in a comfortable setting (typically, at home)—while in a setting that is uncomfortable or challenging for the child with selective mutism (Kehle, Bray, Byer-Alcorace, Theodore, & Kovac, 2011). This allows the child to obtain a "virtual glimpse into communicating successfully in a setting that causes heightened anxiety" (Klein & Armstrong, 2013). This could also involve making a video recording of the child and editing it so that the video shows the child speaking in settings where the child does not speak, such as the classroom. With others present, the child then watches and listens to him/herself speaking and learns to think positively about speaking in front of others (Viana et al., 2009).
DIR (Developmental, Individual Differences, Relationship-Based) Floortime ® is a developmental and interdisciplinary framework based on functional emotional developmental capacities (FEDCs). It utilizes the concepts of self-regulation, attention, engagement, intentional communication, and purposeful problem-solving communication. Goals are based on evaluating the child's FEDC (i.e., moving from nonresponsive, to using gestures, to making sounds, and then to being verbal) and supporting individual differences (sensory processing, praxis, speech and language challenges, visual spatial processing, postural stability) to move the child up the FEDC ladder. It incorporates sensorimotor and play-based activities (often having co-treatments with an occupational therapist) and instruction regarding anti-anxiety strategies from a social worker or other behavioral health professional (Fernald, 2011).
Ritual Sound Approach (RSA), a cognitive and behaviorally based treatment, is a part of Social Communication Anxiety Treatment (S-CAT). RSA first teaches sound production from the mechanical perspective; then, shaping occurs to reinforce oral movements with sounds that gradually progress to phonemes, syllables, and words (Shipon-Blum, 2010). The SLP talks with the child about nonspeech sounds (e.g., breathing, blowing, and coughing). He/she describes how voiceless phonemes are similar to these actions and how these phonemes are produced physically. The child then progresses to approximating voiceless phonemes (e.g., /h/, /k/, /t/, and /p/). Then, using an alphabet board, the child crosses off the sounds that he/she can produce. Looking at the alphabet board also serves as a distraction from needing to make eye contact, which can help reduce anxiety about speaking. The SLP talks about how sounds are blended to form words in RSA's chaining so that voiceless consonants are paired with vowels and other voiceless consonants to form words (Klein, Armstrong, Skira, & Gordon, 2016).
This integrated approach emphasizes participation in social engagement (nonverbal and verbal) at increasingly difficult levels. Shaping and reinforcement, in the context of interactive routines, are used to move the child with selective mutism from acceptance of being a part of joint activities (such as games, art, social play), then using nonverbal communication (reaching, pointing, gesturing yes/no, facial expression) during joint activities, and through a hierarchy of production of sounds (i.e., non-speech sounds to speech sounds, and finally to using words). At the word level and beyond, consideration is given to the hierarchy of using language functions. For example, the child may begin with answering noninvasive questions (e.g., "What color is your shirt?"), and progress to answering increasingly more personal questions (likes/dislikes, family and friends) before eventually being able to ask noninvasive personal questions, and participate in conversation over multiple turns.
When the child changes communicative partners or contexts, tasks may need to be simplified. The approach considers different variables of the communicative context
The Vocal Control Approach (Ruiz, 2013, as discussed in Klein & Armstrong, 2013) uses nonspeech tasks to help the child with selective mutism gain control over voicing and then systematically works to maintain vocal control. The child hums and varies pitch while noting vibration in his nose and throat and then works to extend the length of time humming. The child could also use voice-altering apps while humming to reinforce humming for longer periods of time. Then, the child makes environmental sounds (e.g., animal or engine sounds), with the goal of demonstrating improved voice initiation. Next, the child works to shape the hum into /m/ and add vowels, extending to initial /m/ words and introducing non–/m/-initiated syllables, words, phrases, and sentences.
Generalizing spontaneous speech to different people in a variety of settings may involve (Johnson & Wintgens, 2001; Middendorf & Buringrud, 2009):
Monitoring the individual's success at each level of the treatment plan through ongoing assessment will determine the successful completion of consistent communication with a variety of people in a variety of settings. Anxiety and avoidance behaviors will indicate the need to break down communication steps, locations, or audience size into smaller increments (Kotrba, 2015).
Continued collaboration between the SLP and behavioral health professionals, classroom teachers, and the family is necessary for treatment continuity, clear delineation of roles and responsibilities, and appropriate hierarchical goal setting. Having the SLP on the team, even in a consultative role, helps the child with selective mutism gain confidence in what he/she may perceive as decreased communication skills (Dow et al., 1995).
The SLP can work with the child's teacher and school staff to:
Initially, children may require individual treatment sessions—particularly to establish rapport and to practice relaxation techniques and pragmatic skills—in a safe, comfortable setting. Typically, therapy progresses from child-directed interaction to verbal-directed interaction. During child-directed interaction, the adult observes the child performing an activity that the child chooses, and then the adult joins in, when appropriate, by imitating, describing, and demonstrating enjoyment without asking questions, giving commands, or using negative talk. Verbal-directed interaction allows adults and peers to ask questions, direct some play, and give instructions (Kurtz, 2015; Mac, 2015).
When treating an English Language Learner with selective mutism, it will be important for the SLP to be aware of possible stressors within the child's school setting that will need to be addressed through staff development, interventions, and accommodations (Toppelburg et al., 2005):
Children with selective mutism can also have a concomitant communication delay, disorder, or weakness (Richard, 2011). Children with selective mutism may avoid speaking out of fear of being teased regarding speech sound production or vocal quality (Anstendig, 1999). Evidence of a concomitant communication disorder is not restricted to specific settings or social situations, even when co-occuring with selective mutism.
It may be beneficial to address only selective mutism goals initially, in order for the child to gain some confidence in communicating and to establish a relationship with the SLP, before addressing specific speech and language deficits.
Treatment of adolescents and adults with selective mutism can prove difficult if they report not wanting to talk because they do not see the benefits of speaking. An older individual has also developed strategies to avoid talking and has defined themselves as being primarily nonverbal in a school setting. Increasing internal motivation to elicit behavioral change by helping the adolescent or adult explore and resolve ambivalence through discussion is a client-centered counseling technique called motivational interviewing. A motivational interview for someone with selective mutism could include asking about the positive (i.e., maintaining selective mutism) and negative aspects of selective mutism, exploring life goals and values, and then asking for a decision which hopefully results in a willingness to change and set goals (Kotrba, 2015; Rollnick & Miller, 1995).
Pharmaceutical intervention may be considered with this population to address the social anxiety or phobia (Manassis, Oerbeck, & Overgaard, 2015). It is important for the clinician to consider the behavioral influences and side effects of medications on treatment.
Format refers to the structure of the treatment session (e.g., group vs. individual) provided.
Children may require individual treatment sessions initially, depending on the strategies and techniques being applied, to establish rapport and to practice relaxation techniques and pragmatic skills in a safe, comfortable setting.
Small-group therapy can facilitate communication with peers, beginning with nonverbal play using scripted interactions involving single words and phrases and moving toward the ultimate goal of speaking spontaneously (Klein & Armstrong, 2013).
Forming groups of individuals with selective mutism who are of similar age, cognitive functioning, and speech-language skill is another service delivery model. Groups may need to be adjusted based on progress as individuals advance at their own pace (Kearney, 2010).
Provider refers to the person offering the treatment (e.g., SLP, SLPA, caregiver).
Dosage refers to the frequency, intensity, and duration of service.
For some, intensive treatment sessions for selective mutism may be helpful and can take place in a variety of settings. In the school setting, using stimulus fading and/or shaping, the child's schedule is disrupted for the duration of a week. School staff need to receive training in behavioral intervention so as to continue with appropriate treatment and provide accommodations after the week is over. Intensive group treatment in a summer camp simulates a school setting, and the child with selective mutism can receive intensive practice in a safe setting without interruption to his/her school schedule. Families also receive the benefit of meeting other families who are dealing with selective mutism (Kotrba, 2015).
Setting refers to the location of treatment (e.g., home, school, community based).
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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Schum, R. (2002). Selective mutism: An integrated approach. The ASHA Leader, 7(17), 4–6. Retrieved from https://doi.org/10.1044/leader.FTR1.07172002.4
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Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Selective Mutism page:
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Selective Mutism. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Selective-Mutism/.