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 are 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 et al., 2009).

Most prevalence estimates for selective mutism range between 0.2% and 1.6% (Bergman et al., 2002; Chavira et al., 2004; Elizur & Perednik, 2003; Sharkey & McNicholas, 2012). Prevalence can be somewhat higher among immigrant children, language-minority children, and children with speech and language delays (Elizur & Perednik, 2003; Kristensen, 2000; Manassis et al., 2003; Steinhausen & Juzi, 1996). However, it is important to note that selective mutism must exist in all languages to confirm an accurate diagnosis in these populations (Toppelberg et al., 2005).

There is currently a lack of consensus regarding the incidence and prevalence of selective mutism and gender assigned at birth. While most studies report that selective mutism affects more females than males by a ratio of about 1.5–2.5:1.0 (Cohan et al., 2008; Cunningham et al., 2004; Dummit et al., 1997; Kumpulainen et al., 1998), some studies report that it affects more males than females with a ratio of about 1.3:1.0 (Karakaya et al., 2008) or that there is no difference between genders (Bergman et al., 2002; Elizur & Perednik, 2003).

As with many anxiety disorders, children with selective mutism attempt to protect themselves from the discomfort they experience by avoiding the unpleasant activity (i.e., speaking and/or communicating). Varied characteristics and behaviors associated with selective mutism are a method of self-protection but may be interpreted as deliberately oppositional (e.g., “difficult” or “rude”; Kotrba, 2015). Children with selective mutism are often anxious about communication demands. This anxiety may impair the child’s ability to attend to class instruction and participate fully in school or social expectations (Klein et al., 2019). Misunderstanding such behaviors may complicate the identification of selective mutism.

Individuals with selective mutism may demonstrate the following characteristics and behaviors in specific environments; however, they are not required for a diagnosis (Beidel et al., 1999; Doll, 2022; Kearney, 2010).

Home

• Able to speak to one or more immediate family members.
• Exhibit difficulty speaking to extended family members or close family friends.
• May not be able to speak to immediate family members when visitors are present.
• May refuse to leave home to avoid social communication demands (e.g., school, birthday parties).
• May have an emotional–behavioral response (e.g., tantrum, withdrawal) when the child has an awareness of social and expressive communication expectations.

School and Community

• Exhibit physical manifestations of anxiety: Fight, flight, or freeze response; rigid or restricted body movement; or minimal to no facial expression or eye contact.
• May display emotional–behavioral responses (e.g., clinging to the parent, behavioral meltdowns, school refusal).
• May be perceived as withdrawn, inattentive, or aloof.
• May have difficulty with language processing in specific situations due to a heightened level of anxiety.
• Unable to speak with adults or children in social or educational settings.
• Unable to respond nonverbally or verbally when spoken to; unable to initiate speech to provide information or comment.
• May use nonverbal methods of communication (e.g., body posture, eye gaze, facial expression, gesture) to respond to or initiate with people in settings where they are more comfortable and less anxious.
• Unable to initiate using any mode of communication to request help.
• Unable to speak at school, which impacts both educational performance and social development.
• Unable to speak to immediate family outside the home or when other people are present.
• Unable to speak with unfamiliar communication partners; may be able to use nonverbal modes of expression (e.g., eye gaze, head nod, pointing) over time as they become more comfortable in the social environment.

Additional conditions that may be associated with selective mutism are as follows (Capozzi et al., 2018):

• enuresis (i.e., urine accidents) and encopresis (i.e., bowel accidents)
• eating challenges (e.g., eating with or in front of others, food selectivity)
• sleep disturbance

No single cause of selective mutism has been identified, and its causes may be multifactorial (Cohan, Price, & Stein, 2006). The following factors may coexist and play a role in selective mutism:

• Psychological factors, such as social phobia, separation anxiety, and obsessive-compulsive disorder (Beidel & Turner, 2007; Black & Uhde, 1995; Manassis et al., 2003).
• Hereditary or genetic predisposition of selective mutism and social anxiety disorder (Black & Uhde, 1995; Cohan, Price, & Stein, 2006; Viana et al., 2009).
• Family and environmental factors, such as reduced opportunities for social contact, parenting style, or reinforced avoidance behaviors (Viana et al., 2009).
• Neurological/neurodevelopmental vulnerabilities, such as delays in achieving speech, language, or fine and gross motor milestones (Viana et al., 2009).
• Overactive autonomic nervous system response that impacts physiological, sensory, and emotional–behavioral responses (e.g., Melfsen et al., 2021).
• Other factors, such as shy or timid temperament (American Psychiatric Association, 2022; Steinhausen & Juzi, 1996).

Speech-language pathologists (SLPs) play an integral role in the screening, assessment, diagnosis, and treatment of individuals with selective mutism. The professional roles and activities in speech-language pathology include clinical services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology.

The following roles are appropriate for SLPs:

• Educate other professionals on the needs of individuals with selective mutism and the role of the SLP in diagnosing and managing selective mutism.
• Screen individuals who present with language and communication difficulties to determine the need for further assessment and/or referral for other services.
• Conduct a comprehensive, culturally and linguistically appropriate assessment of speech, language, and communication.
• Aid in diagnosing the presence or absence of selective mutism with an interdisciplinary team.
• Refer to other professionals to rule out other conditions, determine etiology, and facilitate access to comprehensive services.
• Make decisions about the management of selective mutism.
• Develop treatment plans, provide treatment, document progress, and determine appropriate dismissal criteria.
• Counsel individuals with selective mutism and their care partners regarding communication-related issues and provide education aimed at preventing further complications relating to selective mutism.
• Consult and collaborate with other professionals, family members, care partners, and others to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate.
• Remain informed of research in selective mutism and help advance the knowledge base related to the nature and treatment of selective mutism.
• Advocate for individuals with selective mutism and their families/care partners at the local, state, and national levels.
• Serve as an integral member of an interdisciplinary team working with individuals with selective mutism and their families/care partners.

As indicated in the Code of Ethics (ASHA, 2023), clinicians who serve this population should be specifically educated and appropriately trained to do so. SLPs take part in the aspects of the profession that are within the scope of their professional practice and competence. If an SLP has advanced training in and knowledge of selective mutism, diagnosis is possible in accordance with existing state credentialing laws. However, a diagnosis made by an interdisciplinary team ensures that a full differential diagnosis was completed.

Screening

Screening for selective mutism is conducted whenever selective mutism is suspected or as part of a comprehensive speech and language evaluation for a child with communication concerns. If a parent or care partner reports that a child is communicating successfully at home but not in one or more settings, the speech-language pathologist (SLP) may want to consider screening for selective mutism.

Screening typically includes

• norm-referenced parent/care partner and teacher report measures,
• competency-based tools such as interviews and observations, and
• hearing screening to rule out hearing loss as a possible contributing factor.

See ASHA’s Practice Portal pages on Hearing Loss in Children and Hearing Loss in Adults for more information.

Comprehensive Assessment

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.

Assessment of children with selective mutism involves a collaborative approach with an interdisciplinary team, which may consist of a pediatrician, a psychologist or psychiatrist, an SLP, a teacher, a school social worker or guidance counselor, and family/care partners. During the evaluation, parents/care partners may need to help elicit verbal output. The SLP can also involve parents/care partners 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 below for more details.

Case History

A diagnostic interview with parents/care partners and teachers is conducted without the child present to help gather information about the following:

• Any suspected co-occurring disorders (e.g., schizophrenia, autism spectrum disorder).
• Environmental factors (e.g., amount of language stimulation).
• Circumstances of communication (Kotrba, 2015):
  • With whom does the child communicate?
  • In what circumstances is the child most likely to communicate?
  • Where and in what settings is the child able to communicate?
  • How does the child communicate—gestures? writing? sounds? whispering? short responses?
• The child’s symptom history (e.g., onset and behavior).
• Family history (e.g., psychiatric, personality, and/or physical problems).
• Speech and language development (e.g., how well does the child express themself and understand others?).
• Educational history, such as information on academic reports, parent/care partner and teacher comments, previous testing (e.g., psychological), and standardized testing.

If the child is multilingual, the SLP will need to obtain the following information (Mayworm et al., 2015; Toppelberg et al., 2005):

• What languages does the child use now, and with whom?
• How well does the child understand the different languages to which they are exposed?
• Does the child use their primary language successfully outside the home environment? If so, in what settings and with whom?

Speech and Language Evaluation

During the speech and language evaluation, the SLP gathers information on the child’s

• language comprehension;
• expressive language ability;
• nonverbal communication (e.g., pretend play, drawing);
• pragmatic language, including situations, speakers, and contexts that encourage or discourage speech (Hungerford, 2017);
• functional communication ability across various circumstances and settings (Kotrba, 2015; Selective Mutism Anxiety Research and Treatment Center & Shipon-Blum, 2012); and
• oral–motor functioning, including strength, coordination, and range of motion of the lips, jaw, and tongue.

A child with selective mutism might not be able to participate in formal evaluation activities, and they may lack verbal responses and use nonverbal responses (e.g., pointing or gesturing). These behaviors provide diagnostic information regarding the child’s response to social communication. The SLP can also use audio or video recordings from home to supplement parent/care partner descriptions. Any discrepancy between the child’s communication at home and their communication in public may suggest an overarching problem of difficulty with social language.

In some situations, it may be feasible to train parents/care partners, or other familiar adults with whom the child is able to speak, to administer standardized tests (Klein et al., 2013). In these cases, parents can administer test items with the SLP in or out of the room to promote verbal responses from the child; however, the SLP is still responsible for scoring and interpreting test performance. It is the responsibility of the SLP to review the examiner manual to see if parents are listed as a potential assessor based on the prescribed educational and expertise requirements. Using standardized tools in a nonstandardized way may invalidate standardized scores; however, information gleaned from the assessment can still be reported.

Speech Sound Production

Speech sound disorders may occur in children with selective mutism and may magnify the child’s anxiety of interacting with others (Anstendig, 1999). These children may benefit from direct assessment and treatment with parental involvement and support.

See ASHA’s Practice Portal page on Speech Sound Disorders – Articulation and Phonology for more information related to speech assessment and treatment.

Voice

Some children with selective mutism have reported that they do not like their voice, they don’t want their voice to be heard, or their voice “sounds funny” (Henkin & Bar-Haim, 2015; Vogel et al., 2019). 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 (e.g., increased laryngeal tension) for an individual with selective mutism (Ruiz & Klein, 2018). 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 documents vocal quality at the time of the initial evaluation and then reassesses during intervention. The altered vocal quality can lessen as anxiety decreases. Clinicians may also want to evaluate the level of vocal tension during the assessment.

Language Ability

Receptive and expressive language skills may vary in children with selective mutism. For example, expressive–receptive and receptive language disorders may coexist with selective mutism (e.g., Viana et al., 2009). Some children with selective mutism with average receptive language abilities may demonstrate shorter, less detailed, and more linguistically simplistic narratives (McInnes et al., 2004). These subtle deficits in expressive language are theorized to be a compilation of anxiety, mild language deficits, and lack of experience with high-level language skills.

It may be beneficial to use low-stress tasks, such as a picture-pointing task when assessing language ability. If the child is unable to speak, SLPs acknowledge and respond to the child’s gestures or written/typed responses, assess the effectiveness of the child’s attempts at nonverbal communication, and assess the child’s behaviors when engaged in communication. There may be cultural differences within nonverbal communication that the SLP needs to consider when assessing communication.

See ASHA’s Practice Portal pages on Cultural Responsiveness and Social Communication Disorder for further information as well as ASHA’s Practice Portal page on Spoken Language Disorders for more information related to language assessment and treatment.

Cognitive Abilities

While children with selective mutism may demonstrate average cognitive and academic abilities (Manassis et al., 2003; McInnes et al., 2004), some children with selective mutism may have impaired visual memory or auditory–verbal memory (Kristensen & Oerbeck, 2006; Manassis et al., 2007). 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 (Kotrba, 2015).

Social Communication Skills

Social communication skills for children with selective mutism typically appear limited outside the home and other familiar environments and, at times, may appear limited in the home as well. Research is not clear as to whether children with selective mutism have pragmatic language challenges 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 et al., 2003). Home video samples may be helpful in assessing social communication variations across settings.

Please see ASHA’s Practice Portal page on Social Communication Disorder for more information related to assessment and treatment.

Assessment Considerations

Meeting the Child

Prior to initiating speech and language services, the SLP can provide parental or teacher questionnaires regarding selective mutism or conduct a diagnostic interview with parents, care partners, and teachers to prepare for the initial meeting. Clinicians may consider meeting the child one-on-one or with the parent/care partner present prior to formal assessment. Conditions of meeting the child with selective mutism may vary based on the school, home, or private practice setting. The clinician can reassure the parents/care partners and child of the expectations for the first meeting, such as the child will not be pressured to speak, there will be no interruptions, and no one else will be present in the meeting setting (Doll, 2022).

First sessions may be informal and flexible. The SLP may 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. Clinicians may play at the child’s level and follow their lead with open-ended, creative play involving arts and crafts, building blocks, and/or board games (Kotrba, 2015).

The child and parent/care partner may benefit from playing in the assessment room for 5–10 minutes without the SLP in the room to increase comfort and familiarity with the setting. During this time, parents are encouraged to actively engage with their child or ask their child questions to promote verbal output. The SLP can observe if an observation room or video is available. This allows for comparison of the child’s communication with and without an unfamiliar person in the area. Then, the SLP can enter the room, allow the child and parent/care partner to continue playing for several minutes, and then enter the child’s circle of play (Middendorf & Buringrud, 2009).

The following defocused communication strategies can help build a positive rapport and establish trust (Oerbeck et al., 2014):

• Minimize eye contact. Sustaining eye contact from unfamiliar people can make children with selective mutism uncomfortable.
• Maintain a calm demeanor.
• Make environmental modifications. For example, some children may prefer that the SLP sit by their side rather than face-to-face, whereas this may be too close for others.
• Create opportunities for joint attention using an activity that the child enjoys.
• Think aloud by providing behavioral descriptions of what the child is doing, rather than by asking direct questions (e.g., “I see that you’re playing with the truck!” instead of “What are you doing?”).
• Use phrases and terms that encourage the child to communicate, including using the terms “words” or “voice” rather than “talk” or “speak.” The latter two words may have negative connotations for the child (Kotrba, 2015). Also, encourage the child to show, gesture, write, or draw if they are not able to speak (Schum, 2006).
• Reflect back language that the child shares.
• Offer choices or options to respond instead of open-ended or yes/no questions.
• Allow plenty of time for the child to process and respond rather than talking for the child.
• Continue the conversation, even when the child does not respond verbally.
• Receive the child’s responses in a neutral way.

Within an evaluation process, it is also important to be mindful of the communication demands required for specific tasks completed in the evaluation. An SLP may need to modify the order in which they present materials, starting with tasks with no verbal communication demands and moving to verbal communication tasks based on the child’s presentation and responsiveness.

Visit the Selective Mutism Association’s Educator Toolkit for more information.

Interprofessional Collaboration and Referrals

During evaluation and treatment, the SLP may collaborate with and refer to the following professionals:

• audiologist
• behavior analyst/behavioral specialist
• extended family and/or care partners
• family
• guidance counselor
• pediatrician
• psychiatrist
• school or clinical psychologist
• social worker
• teacher

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 impact of those skills on the child’s ability to consistently participate in various settings (Kotrba, 2015). If the SLP is the first professional that a family encounters, the SLP can initiate the collaborative process and provide referrals to behavioral health professionals with training and experience in working with children with anxiety disorders (e.g., behavioral therapists, cognitive therapists). A collaborative interprofessional team that develops a treatment plan and communicates regularly can optimize treatment outcomes and promote generalization of effective communication skills across people, settings, and situations.

See ASHA’s webpage on Interprofessional Education/Interprofessional Practice (IPE/IPP).

Differential Diagnosis

The major difference between selective mutism and other disorders is that the child with selective mutism can talk in certain situations but not others due to anxiety (Kotrba, 2015). SLPs consider whether a child’s absence of speech may be due to a communication disorder, a developmental disorder, or other psychiatric disorders (Kearney, 2010). Diagnosis by an interdisciplinary team, including behavioral health care professionals, ensures a complete differential diagnosis process.

Although selective mutism is not better explained by a communication disorder or psychological disorder, selective mutism may occur simultaneously with the following (Driessen et al., 2020; Steffenburg et al., 2018):

• social anxiety
• generalized anxiety
• separation anxiety
• autism
• specific phobia
• obsessive-compulsive disorder
• speech and/or language disorder (Viana et al., 2009)

SLPs also consider if the child is immersed in a new language environment because acquiring another language is a complex process. When children are exposed to a new language, they may experience a brief silent period in which they are quiet and speak little. Although children may not speak in situations in which the new language is used, children with typical second-language acquisition demonstrate appropriate social communication skills in settings and with people who speak the child’s primary language (Doll, 2022). When working with a multilingual child, diagnosing selective mutism depends on understanding typical multilingual child development. Multilingual 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/care partners to determine if the child speaks in their primary language successfully outside of the home environment is important information for the SLP to gather to inform differential diagnosis (Mayworm et al., 2015). Please see ASHA’s Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology for further information.

It is necessary to collaborate with an interpreter or a translator if the SLP does not speak the language(s) of the child. The SLP should be mindful of the number of people in the room and consider how the introduction of an additional person may impact performance. 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 ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators 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 following 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 may not be 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. See ASHA’s resource on trauma-informed care.

Determining Educational Eligibility

Interprofessional practice and family involvement are essential in assessing and diagnosing selective mutism; the SLP is a key member of a multidisciplinary team. The multidisciplinary team reaches a consensus that assessment results are consistent with the diagnostic characteristics of selective mutism.

Within school settings, children can be supported through informal services, Section 504 plans, or individualized education programs. There is no single, preferred, consistent diagnostic category for children and youth with selective mutism in the school setting. Eligibility for special education services under the Individuals with Disabilities Education Improvement Act of 2004 could be determined to fall within the disability categories of Other Health Impairment, Speech-Language Impairment, or Emotional Disturbance/Disability.

The level of accommodations will depend on the functional impact of selective mutism in the school setting. For example, a newly identified student may need regular access to a “buddy,” someone who the child can speak to throughout the day, versus a student farther in the treatment process may need opportunities to work in small groups with less familiar peers (Doll, 2022). Some children with selective mutism may benefit from the classroom accommodations offered through a Section 504 plan, whereas others may need more direct services within special education to address the communication concerns.

Early intervention for selective mutism is key to remediation. Communication partners sometimes speak for the child with selective mutism when the child demonstrates distress. This “rescuing” behavior may discourage the child’s future speech attempts and results in negatively reinforcing the child’s avoidance of speaking. Treatment works to break the cycle of negative reinforcement. Consistency in the intervention and expectations, at home and in school, of everyone on the team is important. Speech-language pathologists (SLPs) work to provide predictability and control for children with selective mutism, which may decrease anxiety and improve self-image based on mastery of skills in a variety of settings (Kotrba, 2015). Pharmacological treatment may be prescribed by the individual’s treating pediatrician or psychiatrist (Manassis et al., 2016). Clinicians consider the behavioral influences and side effects of medications (e.g., selective serotonin reuptake inhibitors) on speech and language interventions and collaborate with behavioral health professionals, as appropriate.

Monitoring the individual’s success at each level of the treatment plan through ongoing assessment will determine the overall success for consistent communication with a variety of people in different settings. Anxiety and avoidance behaviors will indicate the need to break down communication steps, locations, or audience size into more manageable steps of facing a fear (Kotrba, 2015).

Behavioral and Cognitive-Behavioral Strategies and Definitions

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 (Camposano, 2011; Cohan, Chavira, & Stein, 2006; Kotrba, 2015). Reinforcements may be

• verbal (e.g., praise);
• tangible (e.g., toys, special outings, belongings); and/or
• privileges (e.g., staying up later, having additional time to play a video game, choosing a movie or board game to enjoy with a parent/care partner).

The trained behavioral health professional, SLP, and school staff collaborate to incorporate behavioral and cognitive-behavioral strategies into interventions across settings for children with selective mutism. These strategies include the following.

Exposure-based practice 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 their ability to speak in different situations (Kearney, 2010; Middendorf & Buringrud, 2009).

Systematic desensitization involves the use of relaxation techniques along with gradual exposure to subsequently more anxiety-provoking situations (Cohan, Chavira, & Stein, 2006; Kearney, 2010).

Stimulus fading 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). For example, if a child does not speak in school, then a child’s parent would be brought into the child’s classroom. When the child speaks to the parent, the clinician slowly brings a new person into the room (e.g., a teacher). This process usually includes rewarding the child when they are speaking in the presence of someone to whom they do not typically speak (Middendorf & Buringrud, 2009; Viana et al., 2009).

Contingency management, positive reinforcement, and shaping 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.

Treatment Options and Techniques

The treatment options below include approaches that are within the scope of an SLP, may involve an SLP in an interprofessional team, or may require additional training.

Augmentative and Alternative Communication

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 adapt an AAC system to facilitate classroom communication. Some individuals may use AAC only in the initial stages of intervention. Some individuals may use AAC only in the initial stages of intervention, with AAC faded over time as an individual with selective mutism finds more success with verbal communication. Other clients and their care partners may have long-term preferences for AAC as their primary communication method. In such cases, language and communication treatment goals incorporating the client’s preferred communication modality may be appropriate.

Please see ASHA’s Practice Portal page on Augmentative and Alternative Communication for further information.

Augmented Self-Modeling

In augmented self-modeling, the individual with selective mutism watches a video segment or listens to an audio segment in which they are engaging in a positive verbal interaction in a comfortable setting (typically, at home). This approach may be paired with additional behavioral and cognitive-behavioral strategies, such as positive reinforcement and stimulus fading (Kehle et al., 2011). This process may 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. The child watches and listens to themself speaking to learn to think positively about speaking in front of others.

DIR Floortime®

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 antianxiety strategies from a social worker or other behavioral and mental health professionals (Fernald, 2011).

ECHO Program

ECHO: A Vocal Language Program for Easing Anxiety in Conversation (Ruiz et al., 2022) aims to support individuals, who are of late elementary age through adolescence, who may experience social anxiety related to speaking in certain situations or with certain individuals. This program, which can be implemented by SLPs, bridges the gap from vocalization to conversation. The following three modules include both face-to-face and computer-based interactive activities:

• Module 1—Voice Control: The individual learns how to initiate voice, modulate intonation and volume, and produce speech sounds in words and sentences.
• Module 2—Social Pragmatic Language: The individual learns to use language for different purposes, change language for the listeners or situation, and follow rules for conversation and storytelling.
• Module 3—Role Play: The individual uses the skills learned in the previous two modules to participate in conversational role plays that simulate real life (e.g., school, home, social, public). A cognitive behavioral therapy framework is used to help reduce cognitive distortions (e.g., “Everyone will laugh at me if I talk because my voice sounds funny”).

EXPRESS Program

EXPanding Receptive and Expressive Skills through Stories (EXPRESS): Language Formulation in Children With Selective Mutism and Other Communication Needs (Klein et al., 2018) aims to expand receptive and expressive language skills with five levels of communication (i.e., nonvocal communication through spontaneous vocalization). The EXPRESS approach, which supports the Common Core State Standards for English Language Arts, uses classic children’s stories to correspond with each module to help expand vocabulary and grammar, engage in question–answer routines, improve sentence formulation, and generate narrative language.

Integrated Behavioral Therapy for Selective Mutism

Integrated behavioral therapy for selective mutism, originally developed for children ages 4–8 years, aims to increase successful speaking behaviors in anxiety-provoking situations, habituate speaking-related anxiety, and positively reinforce speaking (Bergman, 2013). Using a combination of behavioral techniques (e.g., stimulus fading, shaping, desensitization) and exposure-based interventions, the clinician systematically and gradually exposes the child to increasingly difficult speaking situations. This program takes place over 24 weeks during the school year.

Intensive Group Behavioral Treatment

Intensive Group Behavioral Treatment focuses on providing a full course of intervention for selective mutism in a condensed period, such as a 1-week summer camp program (Cornacchio et al., 2019). In a 1:1 child–staff ratio, trained counselors and at least one clinical psychologist incorporate aspects of the parent–child interaction therapy and cognitive behavioral therapy in a group setting. Components of the Intensive Group Behavioral Treatment may also include parent training and coaching.

Parent–Child Interaction Therapy for Children With Selective Mutism

Parent–child interaction therapy for children with selective mutism aims to increase verbal interactions in social settings and decrease avoidance behaviors (Cotter et al., 2018). Intervention includes the following two phases that involve specific techniques, procedures, and tasks to promote verbalization:

1. Child-directed interaction (CDI)—This phase focuses on building the child’s comfort with the communication partner and environment (Doll, 2022). The communication partner uses strategies (e.g., labeled praise, reflection, enthusiasm) to provide verbal models of communication and to take away the pressure of the child speaking.
2. Verbal-directed interaction (VDI)—Once rapport is established, VDI is introduced to prompt the child’s speech. Exposure tasks are used to begin generalizing speech to new environments and people (Cotter et al., 2018). Clinicians continue to address CDI skills during the VDI phase.

Social Communication Anxiety Treatment®

Social Communication Anxiety Treatment (S-CAT) uses a multimodal approach to increase the social engagement, verbal communication, and confidence of the person with selective mutism (SMart Center, n.d.). S-CAT focuses on reducing the child’s anxiety about speaking and the parent/care partner’s rescuing behaviors that enable the child’s avoidance behaviors (Klein et al., 2016). Using behavioral and cognitive-behavioral strategies, the clinician helps the individual move through the four stages of communication (i.e., noncommunicative, nonverbal, transition to verbal, and verbal).

The clinician can incorporate the Ritual Sound Approach® into the S-CAT program to systematically increase the child’s comfort with making sounds and words (Shipon-Blum, n.d.). In the Ritual Sound Approach, the clinician teaches and models how sounds are made through a mechanical perspective. Once the child with selective mutism is comfortable with making nonspeech sounds, the clinician can gradually introduce different phonemes. Eventually, the clinician can help the child blend the phonemes into simple words. Involvement of the child, parent/care partner, and school staff is integral to establishing skills across all environments and communication partners.

Social–Pragmatic Approach

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 through

• building acceptance of joining social activities (e.g., games, art, social play);
• using nonverbal communication during social activities (reaching, pointing, gesturing “yes” or “no,” facial expression); and
• using a hierarchy of sound production (i.e., from nonspeech sounds to speech sounds to using words).

The clinician considers the hierarchy of language functions at the word level and beyond. 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.

Tasks may need to be simplified when the child changes communication partners or contexts. The approach considers different variables of the communication context, as follows:

• who the child is communicating with (familiar vs. unfamiliar)
• where the child is communicating (e.g., treatment room, school library, classroom before school starts, in small group inside the classroom)
• the purpose of communication (e.g., regulating another’s behavior, social interaction, joint attention)
• the ability to manage conversation (i.e., multiple turns, repair conversation, select/maintain/terminate conversation, take another’s perspective; Hungerford et al., 2003)

Generalization/Carryover

Several of the treatment programs described above incorporate ways to generalize speaking in new environments and with new communication partners. Overall, generalizing spontaneous speech to different settings and communication partners may involve (Kotrba, 2015; Middendorf & Buringrud, 2009)

• having the individual with selective mutism rate situations and people from “most difficult” to “least difficult” in a hierarchy;
• preparing and reassuring the individual with selective mutism of their abilities by thoroughly explaining the plan to generalize their skills;
• establishing a keyworker, an adult trained in behavioral and cognitive-behavioral strategies, in the school setting;
• changing only one variable at a time (e.g., either the location or the people present);
• moving from structured and carefully planned occurrences to spontaneous and unplanned situations; and/or
• practicing frequently and repetitively.

Interprofessional Collaboration

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 helps the child with selective mutism gain confidence in what they may perceive as decreased communication skills (Dow et al., 1995).

The SLP can work with the child’s teacher and school staff to use the following strategies: Form small, cooperative learning groups that include the child’s preferred peers.

• Help the child communicate with peers in a group by first using nonverbal methods (e.g., signals, gestures, pictures, writing) and then gradually working toward verbal participation.
• Watch for opportunities to reinforce small improvements.
• Reassure others that the child is still comprehending even if they are not talking.
• Try to minimize symptoms—the child may not want to talk, but they can point, show, gesture, or draw.
• Avoid speaking for the child, justifying the child’s silences, or pressuring the child to speak, all of which may reinforce mutism.
• Support peer acceptance of nonverbal participation in classroom and recreational activities.
• Find nonverbal jobs that the child with selective mutism can perform to build confidence.
• Maintain the classroom routine and try making the same request of the child at the same point in the schedule to decrease anxiety.
• Strategize speaking assignments that the individual agrees to complete with the teacher prompting or reminding the student as necessary (Bergman, 2013).
• Arrange one-on-one time with the teacher and student so that they can seek assistance quietly rather than in front of peers (Richard, 2011; Schum, 2002, 2006).

See also ASHA’s webpage on Interprofessional Education/Interprofessional Practice (IPE/IPP).

Special Considerations

Structuring Treatment

Initially, children may require individual treatment sessions to establish rapport and practice relaxation techniques and pragmatic skills in a comfortable setting. Typically, treatment progresses from CDI to VDI. During CDI, the adult observes the child performing an activity that the child chooses, and then, the adult joins in by imitating, describing, and demonstrating enjoyment without asking questions, giving commands, or using negative talk. VDI allows adults and peers to ask questions, direct play, and give instructions (Kurtz, 2015; Mac, 2015). A trained keyworker could also provide behavioral interventions, CDI, and VDI throughout the school environment (Kotrba, 2015).

English Language Learners

The SLP and the interprofessional team incorporate the following considerations when an English language learner is suspected or confirmed of having selective mutism (Mayworm et al., 2015):

• early identification and intervention
• the language(s) that providers use to implement intervention and the role of language development in the type of treatment
• willingness and training of team members to implement interventions in multiple contexts

When treating an English language learner with selective mutism, the SLP is aware of possible stressors within the child’s school setting that will need to be addressed through staff development, interventions, and accommodations (Toppelberg et al., 2005). These may include

• lack of class support for learning another language,
• the potential for negative views of the child’s culture or language used at home, and/or
• limited communication between the parent/care partner and the school.

See Multilingual Service Delivery in Audiology and Speech-Language Pathology and Cultural Responsiveness for more information related to providing culturally and linguistically appropriate services.

Treating Concomitant Speech and Language Problems

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-occurring with selective mutism.

Before addressing specific speech and language deficits, the child may benefit from addressing only selective mutism goals to increase their confidence in communicating and to establish rapport with the SLP.

Adolescents and Adults

Selective mutism may be resolved in childhood; however, selective mutism in childhood may persist into adolescence and adulthood, or it may develop into another anxiety disorder or phobia (Steinhausen et al., 2006). Adolescents and adults with selective mutism may report not wanting to talk because they do not see the benefits of speaking. At times, young adults may have the desire to speak but are unable to speak because of significant anxiety or lack of strategies (Walker & Tobbell, 2015). The inability to speak may bring about feelings of shame, isolation, frustration, and hopelessness because they have difficulty fulfilling expected social roles.

Older individuals often develop strategies to avoid talking and may have defined themselves as being primarily nonverbal. Motivational interviewing is a client-centered counseling technique that helps the adolescent or adult explore and resolve ambivalence through discussion and aims to increase internal motivation for behavioral change. A motivational interview for someone with selective mutism could include asking about the positive and negative aspects of selective mutism, exploring life goals and values, and then determining goals (Kotrba, 2015; Rollnick & Miller, 1995). The client may be more comfortable with sharing their experiences and concerns through online interview methods (Walker & Tobbell, 2015).

Coding and Reimbursement

Payment and coverage of services related to the evaluation and treatment of selective mutism varies based on factors such as the patient’s diagnosis(es), the payer (e.g., Medicare, Medicaid, or commercial insurance), and the patient’s specific health insurance plan. It is important for clinicians to understand coverage policies for the payers they commonly bill, to verify coverage for each patient prior to initiating services, and to be familiar with correct diagnosis and procedure coding for accurate claims submission.

Clinicians use International Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM) codes to describe the patient’s diagnosis and Current Procedural Terminology codes to describe related evaluation and treatment services.

The term “selective mutism” is used to classify this diagnosis within the ICD-10-CM family of codes for behavioral and emotional disorders with onset usually occurring in childhood and adolescence. Clinicians may also report specific diagnosis codes for speech, language, and communication disorders, as needed. Payer policies may outline specific guidelines based on this diagnosis, such as who may assign a diagnosis for behavioral and emotional disorders and what types of services are covered. For example, some payers may only cover services related to this diagnosis under a mental health benefit; this could require an initial evaluation by a physician or mental health professional and limit coverage of evaluation and treatment by an SLP.

For more information about coding, see the following ASHA resources:

• ICD-10-CM Diagnosis Codes Related to Speech, Language, and Swallowing Disorders [PDF]
• Current Procedural Terminology (CPT) Codes for Speech-Language Pathology Services

Service Delivery

Format

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 treatment can facilitate communication with peers, beginning with nonverbal play using scripted interactions involving single words and phrases and moving toward the goal of speaking spontaneously (Klein & Armstrong, 2013). Another format involves forming groups of individuals with selective mutism who are of similar age, cognitive functioning, and speech-language skills. Groups may need to be adjusted based on each individual’s progress (Kearney, 2010).

Some individuals may prefer telepractice to receive treatment. Many of the treatment strategies noted above can be implemented through virtual means (Busman et al., 2020; Hong et al., 2022). The clinician can use technology (e.g., mobile device) to coach the child or care partner through in vivo exposure activities in school or in the community. Telepractice provides increased access to services for children who may not otherwise have access to trained professionals with experience treating selective mutism. It can also allow for increased collaboration between professionals and family members in different settings.

See ASHA’s Practice Portal page on Telepractice for more information.

Provider

Provider refers to the person offering the treatment (e.g., SLP, speech-language pathology assistant, care partner). In treating selective mutism in a school setting, an established and trained keyworker may be the provider of interventions (Kotrba, 2015). A keyworker is an adult in the school setting who is trained to provide consistent behavioral interventions to the student. The keyworker can help the student generalize skills throughout the school environment and communicate with the treatment team.

Dosage

Dosage refers to the frequency, intensity, and duration of service.

Intensive treatment sessions for selective mutism may be helpful for some individuals and can take place in a variety of settings. For example, in the school setting, using stimulus fading and/or shaping can take place over the course of a week; however, an intensive treatment can disrupt the child’s schedule for the duration of a week. With this type of treatment schedule, school staff receive training in the intervention approach to continue with appropriate treatment and provide accommodations after the intensive treatment ends (Kotrba, 2015).

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 their school schedule. Families also receive the benefit of meeting other families who have a child with selective mutism (Cornacchio et al., 2019; Kotrba, 2015).

Setting

Setting refers to the location of treatment (e.g., home, school, community-based). Generalization of skills to new environments is an important aspect to selective mutism treatment. Treatment may occur within the clinical office, school, and community to reinforce the individual’s speaking skills.

ASHA Resources

• Assessment Tools, Techniques, and Data Sources
• Consumer Information: Selective Mutism
• Conquering Challenges of Interprofessional Treatment for Selective Mutism
• Current Procedural Terminology (CPT) Codes for Speech Language Pathology Services
• ICD-10-CM Diagnosis Codes Related to Speech, Language, and Swallowing Disorders [PDF]
• Interprofessional Education/Interprofessional Practice (IPE/IPP)
• Selective Mutism: An Integrated Approach
• Selective Mutism in Elementary School: Multidisciplinary Interventions
• Teaching the Language of Feelings to Students With Severe Emotional and Behavioral Handicaps
• Trauma-Informed Care

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• Bergman, R. L., Keller, M. L., Piacentini, J., & Bergman, A. J. (2008). The development and psychometric properties of the Selective Mutism Questionnaire. Journal of Clinical Child & Adolescent Psychology, 37(2), 456–464. https://doi.org/10.1080/15374410801955805
• Child Mind Institute: Complete Guide to Selective Mutism
• Kurtz Psychology: Selective Mutism Learning University
• RCSLT: New Long COVID Guidance and Patient Handbook
• Striving to Speak: Children’s Books About Selective Mutism
• Selective Mutism Association
• Selective Mutism Association: Educator Toolkit [PDF]
• Selective Mutism Association: Speech Language Therapy and Selective Mutism

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Acknowledgments

Content for ASHA’s Practice Portal is developed and updated 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:

• Sharon Lee Armstrong, PhD
• Brittany Bice-Urbach, PhD
• Rachel Cortese, MS, CCC-SLP
• Emily R. Doll, MA, MS, CCC-SLP
• Joleen Fernald, PhD, CCC-SLP
• Suzanne Hungerford, PhD, CCC-SLP
• Evelyn Klein, PhD, CCC-SLP
• Janet Middendorf, MA, CCC-SLP
• Gail Richard, PhD, CCC-SLP
• Robert Schum, PhD
• Donna Spillman-Kennedy, MS, CCC-SLP
• Robert Thompson, PhD, CCC-SLP

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Selective mutism [Practice Portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Selective-Mutism/