Selective mutism

Does your child appear tongue-tied in certain occasions, a behavior that seems abnormal to you? It could be a case of Selective mutism (SM) that your kid is possibly suffering from. Read and know all about this disease, including its various possible causes, symptoms, treatment options and more.

Selective mutism Definition

It is a disorder in which a child with the ability to speak stops talking suddenly, generally in school or in social surroundings. People affected by this disease are often unable to speak in certain situations or to some specific people.

Selective mutism ICD9 Code

The ICD9 Codes for this disorder are 309.83 and 313.23.

Selective mutism Causes

The disease commonly affects children under 5 years of age. It is not known why the condition develops and what its possible causative factor or factors are. The majority of medical experts are of the opinion that children affected by this disorder inherit a tendency to be inhibited and anxious in nature. The majority of children affected by this ailment are found to have certain type of extreme social phobia.

While parents of such children often have the opinion that their child is refusing to speak, it generally so happens that suffering children are actually unable to speak in some social settings.

Certain children with this disease have a family history of it along with other problems, such as anxiety disorders and extreme shyness which may elevate the risk for problems that are similar in nature.

Earlier, there was a theory that Selective mutism in childhood is possibly the result of an abusive home or social environment. However, this type of claim has not been supported by any scientific evidence. The primary difference between kids who have gone through a traumatic event and those dealing with SM is the point that abused children are unable to talk in any circumstance.

As per current research studies, children with SM do not remain silent willingly. It is best recognized as a childhood anxiety disorder in social communication. It is most likely to be in the spectrum of social phobia and other associated anxiety disorders.

Selective mutism Vs Mutism

The condition is not the same as Mutism. In Selective mutism, affected kids can speak and understand but are unable to utter words in some specific environments. Children suffering from mutism, on the other hand, never speak.

Selective mutism Symptoms

The typical signs and symptoms of this disorder include:

  • Shyness
  • Ability to speak with family or at home
  • Anxiety or fear around people who are unknown to sufferers
  • Lack of ability to utter words in some specific social settings

The pattern of behavior exhibited by sufferers must persist for at least one month to be confirmed as Selective mutism. It is common for children to exhibit such behavior in the first month of their school. Naturally, this period does not count.

In children, the condition is generally detected first when he or she displays marked alterations in speaking behavior in varied situations. In case of very young children, the problem is expressed in school – particularly when they are called upon to recite in a stage or even inside class. Some other typical situations or surroundings include:

  • Performing in front of crowds
  • While being spoken to or instructed by authority figures

Generally, such children are not found to have any difficulty in interacting with others and in other surroundings even though they exhibit difficulties in the above settings. It is only in certain situations that they experience overwhelming anxiety and fear in speaking. The anxiety is often due to the fear of being made fun of or evaluated.

Many SM-affected children never seem to smile and have a blank expression. Many of them have an awkward body language or appear stiff when in a social setting. They may also appear very unhappy and uncomfortable. They may exhibit the following behavioral patterns:

  • Twirling or chewing own hair
  • Turning head
  • Avoiding eye contact
  • Withdrawing to a corner
  • Moving away from the social group
  • Being more interested in playing alone

Others are less avoidant and do not appear as uncomfortable. They may choose to play with one or only a few selected children and not be extremely participatory in group activities. They would still be mute or communicate only moderately with most teachers and classmates.

Those with whom a SM sufferer does not speak to often tend to take it as a personal insult. It must be remembered that a person with this condition does not do it on purpose and not because they do not like some people. It is often due to their own fear of being evaluated or humiliated that draws such response from them. This is common with strangers and even some family members whom SM patients do not see or talk to on a regular basis. At home, they may speak freely and even to an extent that they may be referred to as chatterboxes. People, in the presence of whom SM sufferers appear ‘frozen’, should try to deal very gently and in an easygoing way with such patients to loosen them up and open up with time.

Selective mutism and Sensory Integration Dysfunction

A small number of children detected with SM have a problem called Sensory Integration Dysfunction. This is a form of brain dysfunction that prevents a kid from accepting and comprehending some sensory details. This incapability of processing information leads to panic as a consequence, which leads to speech inability. Other children with SM may not have this dysfunction although they may remain mute in some situations as a result of language anxiety.

In such cases, the condition arises due to speech problems resulting from pressure to speak. This is particularly true for the following categories of children:

  • Those who grow up speaking some other language
  • Those who come from foreign countries
  • Those who had been taught a foreign language

Such children may feel pressured to speak the language used by other kids. This pressure can cause a lot of stress in young minds, resulting in problems in speaking.

Selective mutism Diagnosis

As such, there is no specific test for determining or confirming the presence of this condition. Diagnosis varies on the basis of the history of symptoms experienced by sufferers. The disorder is baffling to psychologists, who are still trying to analyze some common determinants for the diagnosis of this condition.

According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the avoidance feature of social phobia and social anxiety may be associated with this condition. Hence, these disorders should be taken into consideration. Over 90% of SM sufferers also meet the diagnostic criteria for social phobia (earlier referred to as Social Anxiety Disorder). The condition should also be taken into account at the time of diagnosis.

Selective mutism Diagnostic Criteria

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has laid down the following criteria that patients must meet in order to be confirmed of having SM after diagnosis:

  • Inability to speak in a minimum of one particular social situation where patients are expected to speak (such as at school) in spite of being able to speak in other surroundings (such as at home)
  • The condition has interfered with social communication or with occupational or educational progress
  • The duration of the problem is a minimum of one month and is not restricted to the first month of school
  • The lack of ability to speak is not due to a unfamiliarity of or discomfort in using the primary language needed for communication in the social setting
  • The disturbance cannot be better accounted for by a communication disease (such as stuttering) and does not exclusively occur during the course of Schizophrenia or other psychotic or pervasive developmental disorders.

As approximately 20-30% of children with SM have problems with speech and language, doctors often order a thorough speech and language evaluation. Occupational therapy evaluation is also recommended in case motor or sensory issues are found to exist. If the diagnosis is not clear, the following tests are often recommended:

  • Complete physical exam (including hearing)
  • Thorough developmental screening
  • Standardized testing
  • Psycho-educational testing

Selective mutism Differential Diagnosis

SM is often misdiagnosed as another similar condition known by the name Autism Spectrum Disorder. This kind of misdiagnosis happens when a child suffering from SM refuses to talk in the presence of a therapist. There are prominent differences between the two ailments although autistic children may also refuse to speak in some situations. Children with SM simply show an inability or refusal to speak while autistic children tend to avoid eye contact and flap their hands. Physicians should take into account all these disorders and carefully ensure that the symptoms exhibited by sufferers are those of SM and not of any of the aforementioned disorders.

SM is also often misdiagnosed as Asperger’s Syndrome. Due to this reason, a more widespread and comprehensive understanding of the condition and its treatment are required for a more definitive diagnosis.

Selective mutism Treatment

The treatment of this condition involves changing the behavioral pattern of sufferers. The family and school authorities of affected children should participate in the curative program to work for their betterment. Physicians have found safe and successful results by using some medicines that cure social phobia and anxiety.

Treatment of SM mainly depends on the sufferer although psychological counseling plays a major role in almost all cases in helping affected children speak in all situations and circumstances once more.

It is important that parents of SM sufferers take their children to psychologists right away. This type of condition does not resolve with age. Naturally, it should not be ignored or left untreated.

In adult sufferers, treatment can pose problems as speaking up can be very difficult after a lifetime of problems with speech in some social settings. In such cases, physicians might find effective results by encouraging increase in social interaction. They should encourage any behavior or activity that helps patients to speak up freely without any anxiety. Gradually, the activity may be altered or done away with as the sufferer gains confidence in being able to speak freely in any circumstance. However, this type of treatment must be dynamic to help patients make transition into regular speech.

Selective mutism Prognosis

The outcome may vary for sufferers of SM. Some patients may show quick response and be completely cured while others may have to continue therapy for social anxiety and shyness. In the latter cases, treatment may continue into the teenage years and possibly even during adulthood.

Selective mutism Complications

The condition can affect the ability of sufferers to function properly in social settings or school environment. This can be damaging for the academic career and psychological health of sufferers. Lack of proper and timely treatment can make the symptoms worse and patients may even be humiliated and have to face embarrassing consequences for the same. This is common in school where young children make fun of SM patients.

Some severe complications associated with SM include:

  • Worsening anxiety
  • Social withdrawal and isolation
  • Refusal to attend school, poor academic performance, and possible quitting of school
  • Depression and expressions of other anxiety disorders
  • Poor self-confidence and self-esteem
  • Self-medication with alcohol and/ or drugs
  • Academic or professional underachievement
  • Suicidal thoughts and possible suicide

Selective mutism Support Groups

Patients or their friends and family members can contact the following support groups to receive proper information and resources that can help them cope with this disorder.

American Speech-Language-Hearing Association

Official Website –

Selective Mutism and Childhood Anxiety Disorders

Official Website –


If you suspect your child to be exhibiting problems that are similar to Selective mutism, which are affecting his or her performance in school or social activities, get in touch with a professional health care provider. Seeking medical attention in time can help you child grow up as normally as possible and recover from all communication problems with time.


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