Selective Mutism

What is selective mutism?

Selective mutism (SM) is a mental health condition where you can’t talk in certain situations because of fear or anxiety. It usually affects young children, but it can also affect adolescents and adults.

This condition is more than being shy, bashful or timid. SM is an anxiety disorder. It can overlap with other anxiety-related conditions and have lingering effects later in life. 

How common is selective mutism?

SM is fairly rare. It affects less than 1% of people (across all age groups). It almost always begins in childhood around age 5, often coming to attention soon after a child starts preschool, kindergarten or grade school. It’s less common — but still possible — in teenagers and adults.

SM seems to affect women and people assigned female at birth (AFAB) about twice as often as men and people assigned male at birth (AMAB). However, that number may be skewed because of bias or stereotypes about how talkative people should be based on their sex assigned at birth. More research is necessary to determine if the disparity between sexes assigned at birth is accurate.

SM is rare overall, but it’s especially rare in adults. You might recognize the symptoms of it in yourself, or you might recognize them in your child (or a child you care for). Everyone with a diagnosis can benefit from treatment, regardless of age.

What are the symptoms of selective mutism?

The “selective” in this condition’s name means it only happens in certain situations (remember that it’s not a willful or deliberate choice not to talk). If you have SM, you have no trouble talking in comfortable situations. However, you consistently find talking difficult or impossible in uncomfortable situations.

The symptoms can take different forms. Some people are completely unable to talk (or nearly so). Others may communicate less or in limited ways. 

Total or near-total inability to communicate

This is going to great lengths to avoid communicating or avoiding it entirely. It can look like:

• Feeling unable to speak. It can happen because you feel overwhelmed or paralyzed by fear or anxiety. It can appear that you’re refusing to talk, but is an “autopilot” response rather than a deliberate choice.
• Tense or stiff posture, freezing or feeling unable to move.
• A “deer in the headlights” or blank expression.
• Avoiding eye contact.
• Avoiding social interactions or not participating in them.
• Not asking for things wanted or needed (such as a child in school not asking a teacher if they can go to the bathroom, leading to daytime wetting).
• Behaving disruptively (such as throwing temper tantrums) to avoid talking.

Nonverbal communication

• Preferring to use widely understood sounds (such as “uh-uh” for “no” and “uh-huh” for yes) or other noises instead of words.
• Using nonverbal communication to avoid talking (such as writing responses or pointing to things in a book).
• Using gestures or other movements (such as facial expressions, pointing, miming, or nodding or shaking your head) rather than words.

Minimal or reduced communication

• Slowed responses.
• Using single-word responses or very short sentences.
• Mumbling, stuttering or whispering.
• Changing one’s voice (speaking in a robot-like voice or changing one’s natural pitch and tone).

What causes selective mutism?

Experts can’t fully explain why SM happens. However, they suspect several possible factors may cause or contribute to it. These include:

Other mental health conditions

SM has strong connections to other mental health conditions. These aren’t necessarily causes. They’re simply more likely to happen in people with SM. These conditions include:

• Social anxiety disorder. This is extremely common in people who have SM. Experts estimate that 75% to 100% of people with SM also have this.  
• Phobias.
• Other anxiety disorders.
• Autism spectrum disorder.
• Separation anxiety.
• Post-traumatic stress disorder (PTSD).

Family history or genetics

Anxiety disorders can run in families. People with SM are much more likely to have a first-degree relative (a parent, sibling or child) with SM or another anxiety disorder.

Other communication disorders

Some children develop SM because of anxiety related to how they talk or how well they understand others (like from auditory processing disorders or learning delays).

Children can also develop SM because of speech disorders (like stuttering or other forms of fluency disorder). Some children develop SM because they don’t like their voice or feel anxious about how they sound.

Social circumstances

Children with certain social factors or circumstances are more likely to develop SM. These include:

• Being bullied.
• Traumatic events or abuse.
• Family problems (such as emotional, verbal or physical violence in the home).
• Immigrating to a place with a different primary language.

What are the complications of selective mutism?

SM can negatively affect your life in many ways. These can include:

• Social difficulties, loneliness or isolation.
• Developing other anxiety-related conditions or symptoms.
• Impacts on academic achievement or work performance.

How is selective mutism diagnosed?

A mental health provider, like a psychiatrist or psychologist, will usually diagnose SM. Other providers, especially speech-language pathologists or speech therapists, may rule out other conditions to help with the diagnosis.

A provider makes this diagnosis based on symptoms and behaviors. They’ll ask questions about your (or your child’s) experiences and other factors that could contribute to this condition.

Your provider will typically use screening questionnaires, checklists or other tools to help determine if you meet the criteria. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition text revision™(often referred to as “the DSM-5®”) has five criteria that you must meet to receive a diagnosis of SM:

• You consistently don’t talk in social situations where it’s expected, but have no trouble talking in other situations.
• Not talking affects your social, educational or work life, or any combination of the three.
• The inability to talk lasts longer than one month.
• Not talking isn’t because you have trouble speaking or understanding the main language others are using.
• Your difficulty talking isn’t because of another communication disorder like stuttering, and it isn’t only happening in connection with autism spectrum disorder, schizophrenia spectrum disorders or other conditions that involve psychosis.

How is selective mutism treated, and is there a cure?

With treatment, it’s possible to reduce the severity and frequency of symptoms. With early diagnosis and treatment, some people may see the symptoms vanish entirely.

The most common treatment approaches are:

Mental health therapy

Mental health therapy (especially cognitive behavioral therapy, or CBT) is generally the first option. It’s also the most likely to help. Behavioral therapy helps you understand and cope with anxiety and other distressing feelings that cause SM symptoms. It can also help with modifying tantrums or other disruptive behaviors that can happen with SM.

For children, these forms of therapy should involve the people raising them, too. Parental figures (including legal guardians or other loved ones) can contribute to the success of mental health therapy.

Speech therapy

Speech therapy involves working with a speech therapist or another specialized healthcare professional. It can be particularly helpful when SM happens with speech disorders.

Medications

Medications can be part of treatment for SM, especially if mental health or speech therapy aren’t effective on their own.

The most common medications for treating SM are selective-serotonin reuptake inhibitors (SSRIs). These mainly treat depression but can also treat anxiety-related disorders, including SM. Other medications may also help. Your healthcare provider (or your child’s provider) can tell you more about these and help you choose.

Complications/side effects of medications

Your healthcare provider is the best person to tell you about the possible side effects and complications of the specific medication(s) you’re taking, and what you can do to limit or avoid those effects.

Can selective mutism be prevented or can I reduce the risk of it happening to my child?

SM isn't preventable. Experts don’t fully understand what factors can contribute to or cause it, so there’s no way to reduce the odds of it happening.

What can I expect if my child or I have SM?

In children, SM can affect how they do in school, socialize and make friends. It can also cause children to avoid talking even when it’s important.

If you have SM as an adult, it can continue to have negative effects. SM can keep you from making friends or developing relationships (social, work, romantic, etc.). It can also affect how you do at school or at work.

How long does selective mutism last?

For many people, the symptoms seem to disappear by adulthood. The symptoms can still be there, but shift and look more like another anxiety disorder (especially social anxiety disorder).

What’s the outlook for selective mutism?

The outlook for SM is good overall, especially with early diagnosis and treatment. When diagnosed and treated in early childhood, most people with SM can overcome or learn to cope with it, so it doesn’t affect their lives as much (or at all).

When SM goes undetected or untreated, the outlook is less positive. It isn’t dangerous, but the negative effects can be significant. People with SM often experience anxiety and depression. Some struggle with social situations and feel lonely or isolated. It can also affect their education, career and other important parts of their lives.

What can I do to help my child if they have selective mutism?

You may feel frustrated if your child won’t speak in certain situations, even if you tell them to. That frustration can be intense if your child avoids talking by using tantrums or other forms of acting out behavior. 

It’s important to remember that SM is a mental health condition. It’s not something your child has control over. But you can control how you react to your child’s condition and its symptoms.

Some of the most important things you can keep in mind include:

• Help your child feel comfortable and safe. Don’t push or hurry your child into situations where they’ll likely feel afraid or anxious. It’s best not to talk about their issue in front of them because that can make them feel embarrassed or even more anxious.
• Reduce fear and anxiety, and build slowly from there. Start with ways that your child can comfortably communicate and encourage that. Help them become more and more comfortable with social encounters first and then work on talking.
• Be patient and give your child time to talk. Talking for your child can reinforce their sense that they’re doing something wrong and make it harder for them to overcome their fear and anxiety around talking. Make sure they know it’s OK to pause and think before responding, too.
• Praise their efforts. When your child talks, praise them for doing so. And be sure to reward what they did specifically. Make sure they know that their talking had a positive impact.
• Don’t use punishment as a motivator. Children who fear punishment for not talking may find it even harder to talk because they’re more afraid or anxious.

What triggers selective mutism? 

SM “triggers” are situations or circumstances that make it likely that someone with SM won’t talk. Some common examples include:

• Feeling as if others are standing too close or intruding on personal space.
• Others talking loudly or behaving aggressively or strictly.
• People who are unfamiliar or are strangers.
• Physical characteristics of others, like people who are very tall or imposing.
• Nonverbal cues or behaviors, like anxious behavior patterns, or unfriendly or negative nonverbal cues.
• Crowded or loud spaces.
• Places that have connections to unhappy or unpleasant memories.
• Never-before-visited places.
• Situations that are totally new or that your child has an unsuccessful past experience with.

The above list is just some of the more common triggers. Some people may have specific triggers that aren’t like those listed above. Triggers can also shift and change over time.

Is selective mutism a form of autism?

No, SM and autism spectrum disorder are separate conditions, and experts group them into separate categories. However, autistic people are more likely to have SM.

A note from Cleveland Clinic

Selective mutism is a condition that makes you unable to talk in certain situations because of fear or anxiety. It’s likely to start in childhood around school age but can also affect teens and adults. It’s important to remember that children who have it aren’t being disobedient or stubborn, and SM isn’t something they can control by themselves.

If you suspect your child has SM, talk to their pediatrician or another healthcare provider. Treatments are available, and the outlook is generally positive (especially when treatment begins early). With encouragement and support, your child can learn to speak for themselves without letting fear or anxiety deprive them of their voice.