Written by Dr. Inez Van Roy on
January 2, 2022
Reading Time: 7 minutes

Medically Reviewed by our Medical Affairs Team

Written by Dr. Inez Van Roy on:

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If you’ve never heard of selective mutism, you’re not alone. Selective mutism is a rare condition that affects communication.t

What is it exactly? This condition can come with such high anxiety symptoms that it feels impossible to speak in certain situations, even if they want to. What are the signs and symptoms? How can it be treated? And what causes the freezing when they are in these social situations?

Here’s everything you need to know about selective mutism.

What is selective mutism?

You might have noticed that you have a shy and rather introverted child. That is totally fine. We are all different, and children have the right to prefer certain settings over others. Your shy toddler started school this year. 

Their teacher requested a meeting as they refused to speak in class. Some teachers might describe your toddler as difficult to handle, stubborn, or not social. These signs might be an interpretation of an adult struggling to communicate with your child.

Your child might be afraid to speak and can’t verbally with this new and strange person. Adults tend to take this lack of communication personally.

If these symptoms keep going on for longer than one month, it might be useful to look deeper at the cause of your child’s behavior. Your child is not necessarily bad or stubborn; they might have another issue.

SM Causes 

People don’t really know what causes selective mutism. It might be a combination between genetics, a bad experience, or an environment. The truth is that there is still a lot of research needed on the topic of selective mutism. 

Today selective mutism is categorized as an anxiety disorder. Like other anxiety disorders, they might inherit a form of anxiety or predisposition for mental health issues.  Some researchers link this form of mutism to social anxiety or too anxious parents.

Other researchers believe it might be an environmental trigger. Maybe the child experienced a traumatic life event that heightened their anxiety in social situations. Not all researchers can confirm this hypothesis. 

In the late ’90s, some theorists believed that selective mutism might also depend on faulty family relationships. It might even serve a purpose in the system. 

While adults could interpret this behavior as defiant or shy, it is not the case. The child can usually speak in other situations. Shyness also doesn’t paralyze anyone. It is also not defiant; the child doesn’t make a conscious decision not to speak. 

Lastly, it is not because the child doesn’t speak in all situations that it is necessarily caused by a speech or language disorder. One study did find a possible connection with a history of language developmental delays. Still, most other researchers agree that this is not the cause. 

In short, we still don’t understand the cause. 

SM Signs and Symptoms

Selective mutism is a mental disorder, usually diagnosed very early in life. The child usually can’t speak in certain situations, while they don’t have that problem at home.

The DSM-5 (Diagnostic and statistical manual) describes the following signs and symptoms:

  • Can’t speak consistently in social situations where speaking is expected. In other situations, they can speak with ease.
  • The child, adolescent, or adult is obstructed in achieving their professional and educational goals. This is due to their lack of social communication.
  • They have been suffering from selective mutism for at least a month.
  • The lack of communication is not due to a speaking disability or a lack of knowledge.
  • The disorder is not due to a communication disorder.
  • Autism, schizophrenia, or another psychiatric disorder aren’t the cause either.

In short, at a certain point in time, your child refuses to speak to certain people. That might be at school and might have to do with feeling anxiety or stress in such a situation.

Who is at risk for selective mutism?

Selective mutism is a very rare disorder. It is most common in early childhood (3 – 6 years). However, it still happens in older children and adults as well.

The prevalence of social mutism is very low. Statistics range from 0,03 to 0,76 percent of the population.

Girls might suffer more from this mental illness than boys. 

SM Diagnosis

Diagnosing selective mutism is not something you do alone as a parent or teacher. Trained professionals can help guide you through this process. If the person with SM is an adult or teenager, there are ways to connect and include them in this process.


Diagnosing starts with interviewing the parents, teachers, and health professionals. 

It is important to screen for any neurological, speech, or language difficulties. Further, these people can give insights into how the child is attaining their developmental milestones. 

Teachers and clinicians can observe in which situations the child communicates. They can also observe whether non-verbal communication is happening. 

A psychologist or psychiatrist can use testing tools to evaluate the person’s overall mental health. 

Lastly, a licensed professional should do a speech and hearing test. It is always possible that selective speaking (or not speaking) is a biological problem. This should be evaluated.

As you can see, diagnosis right now is mostly based on external interpretation of the behavior of a child or adult. While these observations can give good information, there are still no facts. A shortcoming of this strategy is that the child or adult is not heard. A teacher might describe them as shy, while that is not the case. 

Diagnosis in Teenagers and Adults

Teenagers with selective mutism don’t tend to describe themselves as introverts. Adults with SM report that they are just better at avoiding situations. 

Research shows that adults with SM feel socially isolated. This can start a vicious cycle that maintains anxiety. This can be accompanied by a profound sense of loss, their identity, their future and past, and their social interactions.

This research showed these themes to be important for people with SM. It also showed great resilience against despair and isolation. These researchers propose to include practical methods to support inclusion and belonging. 

While it is not easy to communicate with them, it is important to try and find a way that works for them. A skype messaging system could, for example, be used, so they get a say in their own treatment and diagnosis plan.

SM Management and Treatment Options

Selective mutism still needs a lot of research. This makes it more difficult to treat. In the first instance, treatment focuses on removing the pressure to speak. 

Many forms of therapy focus on helping the child relax and cope with their anxiety. There might be an aspect of play, music, or art involved as a way to lower the pressure.

Cognitive-Behavioral Therapy

CBT or cognitive-behavioral therapy is a proven way to treat many mental disorders. Usually, it focuses on the thoughts and behaviors accompanying the mental illness.

The thoughts and perceptions about the world, ourselves, and others are observed as well. So some introspection is usually necessary. That makes these interventions more suited for older children, adolescents, and adults. 

Behavioral Therapy

Behavioral techniques are common in conjunction with another form of therapy (like CBT or systemic therapy). These techniques usually focus on the behavior and not the underlying feeling.

Some popular techniques could be:

Shaping or ritual sound approach

The therapist reinforces mouth movements or sounds. They break down speaking in smaller steps to decrease anxiety.


This old technique (1998) cuts up audio recordings of the child after these get edited in a way that the child would answer common questions in the feared environment.

The child is supposed to listen to it and become more comfortable with hearing themselves in such a setting.

Positive and negative reinforcement:

Behaviorists say that positive reinforcement to all communication can motivate to talk more. The environment also shouldn’t discourage the child from speaking by just taking over or pressuring them to speak. This will only give them more anxiety and stress, and the feeling of avoidance and silence is a better option.

They might also feel amazing after the moment passes. The sweet taste of relief won’t improve the connotation between speaking and their inner experience.

Graded exposure:

Exposure is usually a part of treatment in anxiety disorders. A therapist can set up a safety plan for exposure. Together with the client, they will set up goals and targets of repeated exposure to the feared situations. The exposure will grow from least feared situation to most feared situation. 

Stimulus fading:

The child, adult, or adolescent gets gradually exposed to speaking with other people present. The person with selective mutism usually can speak in their own environment with their trusted parent, partner, or family member.

This trusted person will be available until the person with selective mutism feels comfortable speaking with the new person. After, the trusted figure withdraws from the situation. Slowly others will be introduced into this group. This will be in combination with positive reinforcement.


Some might already feel uncomfortable with the thought that others are hearing their voice. This technique reduces the sensitivity to that.

Usually, people can start with sharing texts to voice recordings. This can progress to voicemails, video recordings, and later direct communication.


Medication is sometimes used in extreme cases of mutism. Many physicians are not keen on recommending this as a treatment option for children. Still, many children are unresponsive to psychotherapy. 

A recent review (2016) showed that the following medication is used to reduce the mutism symptoms:

  • SSRIs (selective serotonin reuptake inhibitors) and
  • MAOIs (monoamine oxidase inhibitors).

Children saw an improvement in their symptoms after using SSRIs. Children who took phenelzine (an MAOI) also saw an improvement in symptoms.

However, only four children of the whole sample took these, so it would not be great to draw valid conclusions from such a small sample size.

As stated above, people wouldn’t be keen to recommend this as a treatment option for the children.

Adults or adolescents with selective mutism usually also get the advice to focus on therapy first. If needed, an antidepressant (like the above SSRIs) can be prescribed by your doctor.

How does SM differ from shyness?

Shyness is not the same as selective mutism. Shyness is a personality characteristic. While shyness can also impede someone from talking, it does not paralyze their life. Selective mutism is a disorder; it impedes a child or adult’s social and educational development.

Is SM a Speech Disorder? 

SM is not a speech disorder. This disorder does affect speech and communication, but not in all situations. Usually, they speak perfectly well in other situations.

The American Psychiatric Association categorizes selective mutism as an anxiety disorder. The reluctance to speak might be due to anxiety or fear.

When to Seek Professional Help

If you think your child may be struggling with selective mutism, it’s important to seek help. Early intervention is key to helping your child overcome this challenge.

Usually, this condition gets noticed while going to school. You should contact your pediatrician if the child has not made any adaption after the first month of school and is not communicating.

Talk to your pediatrician or a therapist who specializes in selective mutism about the best treatment plan for your child. There are many resources available to help you and your family get through this difficult time. With the right support, your child can learn to speak up and feel comfortable speaking in any situation.

If your child is not speaking for more than a month (without any progress), then it would be good to seek help.

Concluding Thoughts

Selective mutism is a disorder that causes children to be unable or unwilling to speak in certain social settings. Not only are children victims of this condition, sometimes they carry it along until adulthood.

As you can imagine, selective mutism has an impact on these peoples’ lives. It can lead to low self-esteem and poor relationships with friends and family members.

While we are still not sure about the cause of this condition, treatment is available. This is mostly focused on managing the anxiety symptoms accompanying the illness.

If your child seems reluctant or incapable of speaking around others, take them to a doctor. If you have other anxiety symptoms and would like to learn more about mental health, check out these helpful resources. You can also join this online community for more information on mental health and how to live a holistic life. 

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