A parent comes in and says, “I don’t understand why Jimmy won’t talk at school. He loves playing games with his siblings and we practice our letters together every day. Why is he being like this? I could tell he was nervous when I dropped him off on the first day of kindergarten, but why hasn’t he spoken at all yet?”
This may be a confusing narrative for a clinician who is unfamiliar with the diagnosis, but it is a common story we hear from parents of kids with selective mutism.
Selective mutism (SM) is a complex anxiety disorder where a child consistently fails to speak in specific social situations, most often at school, despite being capable of speaking comfortably in other environments, like at home.
It can be confusing for parents who see their child as talkative and bubbly at home, only to be shocked when a teacher reports they have not uttered a single word in class. Sometimes, SM’s effects can be limited to a child’s interactions with certain individuals, such as a teacher or waiter, or to certain spaces, such as the school building.
Selective mutism is not typical shyness
It is easy to misinterpret the signs of SM. Parents often describe their children as “shy,” and some may think their child is being oppositional by refusing to respond when they are clearly capable of talking elsewhere.
However, SM is distinct from typical shyness. Shy children generally warm up to new situations over time. Unlike shy children, those with SM remain unable to speak even after they have become comfortable in a setting. In fact, SM cannot be diagnosed during the first month of school, because this is considered a natural warm-up period for many children.
SM vs. social anxiety
While SM and social anxiety frequently co-occur, there is a key behavioral difference. Children who have SM without broader social anxiety often participate fully in nonverbal ways. For instance, a child with SM might happily run around with peers on the playground even if they cannot talk to them.
In contrast, a child with social anxiety may not play with other children, or may be too afraid to get up in the middle of class to use the bathroom for fear of being noticed. Children with SM can have co-occurring social anxiety, but they can also have SM without additional social anxiety symptoms.
Treatment options
The gold standard for treating SM is behavioral therapy using exposure techniques. Initially, therapists use play therapy skills to build confidence and encourage speech in the therapist’s office. Then, therapists work with families to develop a goal ladder: a list of feared situations ranked based on distress.
For some children with SM, a ladder may look like talking with a parent in an empty classroom, then talking with a parent while a teacher is sitting in the corner, then responding directly to the teacher, and so on. For a child with severe selective mutism, initial goals might be communicating nonverbally with pictograms or gestures, then moving toward whispering single words. Ladder climbing continues until the child can speak with a regular voice in all settings.
Another key component is parent and teacher training. Parents and teachers have the greatest influence over the child’s daily environment. By changing how caregivers respond to anxiety, caregivers can directly influence how the child learns to handle difficult situations.
One effective form of treatment is Parent Child Interaction Therapy adapted for Selective Mutism (PCIT-SM), which combines caregiver training with behavioral exposure therapy. The therapy teaches caregivers skills to grow children’s comfort and confidence, reduce avoidance cycles, and target verbal exposures.
School-based interventions, such as 504 accommodation plans, and medication management may also be important when behavioral therapy alone is not sufficient.
In some cases, symptoms of SM may disappear on their own. However, it is highly recommended to seek intervention as soon as possible. If left untreated, SM can lead to academic impairments or safety concerns because children cannot effectively communicate their needs to teachers or other adults. Co-occurring symptoms of social anxiety may also remain and persist into adulthood.
At Gordon Therapy Group, multiple therapists are specially trained in evaluating and treating individuals with SM. If you have concerns or questions about your child, please reach out for a consultation.