Selective Mutism in Children: Signs, Causes and Help

What is selective mutism?

Selective mutism is an anxiety disorder in which a child who speaks comfortably in some places, usually at home, consistently cannot speak in others, such as with classmates at school or with relatives they rarely see.⁠^1,2 The expectation to talk triggers a freeze response, with anxiety and panic, and in that moment talking is impossible.⁠²

ASHA, the professional body for speech-language pathologists, describes it as a complex anxiety disorder that affects pragmatic language. Despite the name, children with selective mutism do not choose where to speak; they are more comfortable speaking in some situations than in others.⁠¹

Is selective mutism an anxiety disorder?

Yes. The DSM-5 moved selective mutism into its chapter on anxiety disorders, and the World Health Organization’s ICD-11 lists it among the anxiety or fear-related disorders.⁠^10,11,12

The overlap with anxiety is large. In a 2020 meta-analysis of 22 studies and 837 children, 80% of children with selective mutism had at least one other anxiety disorder, most often social anxiety disorder, at 69%.⁠⁶ Some researchers still question the classification, partly because a fifth of the children had no additional anxiety diagnosis.⁠^6,10

Is selective mutism a choice?

No. A child with selective mutism does not refuse or choose not to speak; in NHS guidance’s words, they are literally unable to speak in that moment.⁠²

Because the silence can look deliberate, children are often read as rude, stubborn or oppositional, and ASHA notes that misunderstanding these behaviors can delay identification.⁠^1,2 Treating the silence as defiance adds pressure, and pressure makes speaking harder; see why pressure backfires.⁠²

What is the difference between selective mutism and elective mutism?

They are the same condition under an old and a new name. The Swiss child psychiatrist Tramer proposed “elective mutism” in 1934, believing such children deliberately chose silence. The DSM-IV replaced the term with “selective mutism” to express that the mutism belongs to specific contexts rather than being necessarily self-chosen.⁠⁶

An older label, often written “aphasia voluntaria”, goes back to the German physician Kussmaul in 1877. A 2020 review points out that the term he actually used was “aphrasia voluntaria”, meaning a voluntary absence of speech; he linked the condition mainly to what he called hysteria and other neuroses.⁠⁶

What are the signs and symptoms of selective mutism?

The defining sign is the contrast: a child who chats freely at home goes still and silent when expected to talk to someone outside their comfort zone, often with a sudden stillness and a frozen facial expression.⁠^1,2

• Freezing when spoken to

  A fight, flight or freeze response: a rigid body, little or no facial expression and little eye contact when speech is expected.⁠^1,2

• Gestures, nods or a whisper

  More confident children nod, point or whisper; more severely affected children avoid any communication, spoken, written or gestured.⁠^1,2

• Talkative at home, silent elsewhere

  Talking with close family at home, but not with teachers, classmates, relatives or family friends, and sometimes not even with parents when visitors are present.⁠^1,2

• Meltdowns after school

  Temper tantrums when they get home from school, or anger when questioned by parents.⁠²

The same child may speak in one place and not another, or to one person and not another. ASHA describes three factors, the person, the place and the activity, that can each trigger the mutism, and speaking is hardest where it is expected, mostly at school.⁠¹

What does selective mutism look like at home?

At home most children speak freely with parents and siblings. Difficulties tend to show with extended family, family friends or visitors, and some children refuse to leave the house to avoid occasions, such as birthday parties, where they would be expected to talk.⁠^1,2

Many parents see the strain after school, as tantrums, anger when asked about the day, or withdrawal.⁠^1,2 Some children also have toileting accidents, trouble eating in front of others or picky eating, and sleep problems, which ASHA lists among associated difficulties.⁠¹

What does selective mutism look like at school?

At school a child may not answer the teacher, ask for help or talk to classmates, and may be seen as withdrawn, inattentive or aloof.⁠¹ Some cannot ask to use the toilet and hold on for hours, or avoid eating and drinking all day so they do not have to excuse themselves.⁠²

Particular activities can bring on the mutism even with familiar people; ASHA gives reading aloud and music class as examples.⁠¹ Children may also struggle with homework or whole topics because they cannot ask questions in class.⁠²

What are the DSM-5 criteria for selective mutism?

The DSM-5-TR, the 2022 text revision of the American Psychiatric Association’s manual, sets five criteria for selective mutism, which ASHA’s practice portal reproduces.⁠¹

1. Consistent silence where speech is expected. A consistent failure to speak in specific social situations where speaking is expected, such as school, despite speaking in other situations.⁠¹
2. It gets in the way. The lack of speech interferes with schoolwork, work or social communication.⁠¹
3. At least a month. It has lasted at least one month, and not only the first month of school.⁠¹
4. Not a language barrier. It is not explained by not knowing, or not being comfortable with, the language spoken in that situation.⁠¹
5. Not better explained. It is not better explained by a communication disorder, such as childhood-onset fluency disorder, and does not occur only as part of autism, schizophrenia or another psychotic disorder.⁠¹

NHS guidance follows similar diagnostic guidelines but allows two months, rather than one, when a child is in a new setting.⁠²

What is the ICD-10 code for selective mutism?

In ICD-10-CM, the US version of ICD-10, selective mutism is code F94.0, in the F94 group of childhood disorders of social functioning, alongside the attachment disorders of childhood.⁠^1,13 In the World Health Organization’s ICD-11 it is code 6B06, under anxiety or fear-related disorders.⁠¹²

How common is selective mutism?

Selective mutism is uncommon but not as rare as once thought: most estimates fall between 0.2% and 1.6% of children, and NHS guidance puts it at about 1 in 140 young children.⁠^1,2,14

More girls than boys are diagnosed in most studies, at about 1.5 to 2.5 girls for every boy, though some studies find no difference.⁠^1,16

At what age does selective mutism start?

Selective mutism usually begins in early childhood: NHS guidance gives ages 2 to 4 as the most common start, and ASHA ages 3 to 6.⁠^1,2 It is often first noticed when a child starts preschool or school and has to interact with people outside the family.⁠^1,2

Diagnosis often comes years later. In Norway’s registry of 1,591 young people, the average age at diagnosis was 10.1, and in a sample of 97 children at a center that assesses autism, symptoms began at 4.5 on average but were diagnosed at 8.8.⁠^16,17

What does selective mutism look like in toddlers and preschoolers?

In toddlers and preschoolers it can look like extreme shyness: talking at home but staying silent at preschool, freezing when an unfamiliar adult speaks to them, and answering, if at all, by nodding or pointing.⁠^1,2 The one-month rule matters at this age, since the diagnosis is not made on the first month of school alone.⁠¹

Age matters for treatment. In a study of 24 children treated between ages 3 and 9, 78% of those aged 3 to 5 no longer had selective mutism a year after treatment, against 33% of those aged 6 to 9.⁠⁸ NHS guidance tells parents not to accept the view that a child will grow out of it.⁠² See preschool development for the signs worth acting on before school.

Can teenagers and adults have selective mutism?

Yes. Selective mutism can persist into adolescence and adulthood, or give way to another anxiety disorder or phobia.⁠¹ A 2026 review of 40 mostly small studies of young people aged 10 to 24 found that, compared with children, they had a later onset, longer delays before diagnosis and a longer history of others accommodating their silence, which made treatment harder.⁠¹⁸

Older children and adults can still improve. NHS guidance says adults can overcome selective mutism, though years of limited social contact can leave their mark, and ASHA describes feelings of shame, isolation, frustration and hopelessness in teens and adults who want to speak but cannot.⁠^1,2 See teens for how anxiety and depression show up from 13 to 17.

What causes selective mutism?

No single cause has been found. Selective mutism appears to grow from genetic, temperamental, environmental and developmental factors acting together, and it is classified as an anxiety disorder.⁠^1,11

• An anxious temperament and family history

  A shy or timid temperament and a family history of anxiety: 37% of parents of children with selective mutism had had generalized social phobia, against 14.1% of other parents.⁠^1,19

• Speech, language and motor delays

  In one study of 54 children with selective mutism, 68.5% had a developmental disorder or delay, against 13% of controls; ASHA lists speech, language and motor delays.⁠^1,20

• A new language or a move

  Rates are higher in immigrant and language-minority families: 2.2% of immigrant preschoolers in one Jerusalem study, against 0.76% overall.⁠^1,15

• A nervous system on high alert

  ASHA lists an overactive autonomic nervous system response, which affects physical, sensory and emotional reactions, among possible factors.⁠¹

• Family and environment

  Fewer chances for social contact and avoidance that gets reinforced; in a Finnish registry of 860 cases, two parents with any psychiatric disorder nearly tripled the odds.⁠^1,21

• Hearing or speech problems

  A speech and language disorder or a hearing problem can make speaking even more stressful for an anxious child.⁠²

Family patterns run strong in the early research: in a study of 30 children, 70% of families had a first-degree relative with social phobia and 37% one with selective mutism.⁠⁷ Experts regard selective mutism as a fear, or phobia, of talking to certain people.⁠²

Is selective mutism caused by trauma?

Usually not. In an early study of 30 children with selective mutism, there was no evidence of a causal link between psychologically or physically traumatic experiences and the mutism.⁠⁷

Mutism after trauma follows a different pattern. The child stops talking suddenly, in places where speaking used to be easy, and ASHA notes that children who do not speak after trauma are mute in all settings.⁠^1,2 A child who spoke well before a traumatic event may need help adjusting to the trauma rather than a selective mutism diagnosis, and ASHA advises referral to a behavioral health professional.⁠¹

Is it selective mutism or shyness?

A shy or timid temperament is one risk factor for selective mutism, but the disorder is more than shyness: the silence is consistent, tied to particular people and places, lasts at least a month and gets in the way of school or friendships.⁠¹

Selective mutism also overlaps with social anxiety disorder, which most children with selective mutism have as well; social anxiety in children explains how that condition looks.⁠⁶

Is it selective mutism or the silent period of learning a second language?

Children exposed to a new language often go through a brief silent period in which they are quiet and speak little; with people who speak their first language, they communicate normally.⁠¹ That is part of learning a language, not selective mutism.⁠¹

Multilingual children with true selective mutism are mute in both languages, in several unfamiliar settings, and for long periods, and the diagnosis requires that the silence not be explained by unfamiliarity with the language.⁠¹

How is selective mutism different from other kinds of mutism?

Mutism means not speaking, and it has more than one cause. What sets selective mutism apart is that the child can talk in certain situations but not others, because of anxiety.⁠¹

After trauma. Mutism that follows a traumatic event usually appears suddenly, in places where the child used to talk freely, and in all settings.⁠^1,2

After brain surgery. Speech can also be lost for neurological reasons. One example doctors have defined by international consensus is post-operative pediatric cerebellar mutism syndrome, the mutism some children develop after surgery for a tumor of the cerebellum.⁠²²

Overload and shutdown. Some children who have trouble processing sensory information, such as loud noise and jostling crowds, can shut down and be unable to speak when overwhelmed in a busy place.⁠²

Autism and psychosis. The DSM-5 does not diagnose selective mutism when the silence occurs only as part of autism, schizophrenia or another psychotic disorder.⁠¹

Old names. Elective mutism and aphasia voluntaria are earlier names for selective mutism itself, not separate conditions; the nineteenth-century idea of a voluntary or hysterical silence has given way to its classification as an anxiety disorder.⁠⁶

If your child has stopped speaking where they used to speak, especially suddenly, tell their doctor promptly; ASHA advises referral to a behavioral health professional after trauma.⁠¹

What conditions commonly occur with selective mutism?

Most children with selective mutism have at least one other condition, most often another anxiety disorder.⁠⁶ In Norway’s registry, 51.4% of young people with selective mutism were diagnosed with another mental disorder.⁠¹⁶

Because mutism can hide other problems, a full assessment looks beyond the silence; one study’s author concluded that the mutism may conceal developmental problems.⁠²⁰

Is selective mutism a form of autism?

No. They are separate conditions, but a child can have both.⁠² The DSM-5 diagnoses selective mutism only when the silence is not explained solely by autism.⁠¹

The overlap may be larger than once thought. At one center that specializes in autism assessment, 63% of 97 children with selective mutism also had autism, and they tended to have later onset, later diagnosis and more often a history of speech delay.⁠¹⁷ A 2021 study, reported in a 2023 review, found that 1% of 2,199 autistic children had been diagnosed with selective mutism in childhood, against none of 460,798 controls.⁠⁹

A 2021 review argued that autism-related difficulties, not only anxiety, are sometimes part of selective mutism.⁠²³ NHS guidance notes that autism has other signs, such as repetitive behavior and sensory issues, as well as difficulties with communication; see autism.⁠²

Is selective mutism linked to ADHD, OCD or depression?

Obsessive-compulsive disorder occurs in about 6% of children with selective mutism, and ASHA lists it among the conditions that can occur alongside it.⁠^1,6 See OCD in children.

ADHD has been studied less. In one small study of 23 children with selective mutism, a difference from controls on an attention test disappeared once motor skills and IQ were taken into account.⁠²⁴ See ADHD for how attention problems are assessed.

Depression can develop as children grow. Long-term studies found depressive symptoms in only a couple of samples, probably because half of them followed children only through childhood, and NHS guidance reserves medicine mainly for older children and teenagers whose anxiety has led to depression.⁠^2,9 See childhood depression.

Do sensory sensitivities play a part in selective mutism?

They may, for some children. NHS guidance describes children who struggle to process sensory information shutting down and becoming unable to speak in a busy setting, and ASHA lists an overactive nervous system response, affecting sensory and emotional reactions, among possible factors.⁠^1,2

The research is early. In a parent survey of 75 children, those with both selective mutism and autism showed more sensory avoidance than those with selective mutism alone, and sensory avoidance helped explain their higher social anxiety.⁠²⁵ A small 2026 study of 3- to 6-year-olds found higher sensory processing sensitivity in children with selective mutism than in their peers.⁠²⁶ Sensory over-responsivity explains how sensory overload differs from anxiety.

How is selective mutism diagnosed?

Selective mutism is diagnosed from a detailed history from parents and teachers, observation of the child, and a check against the diagnostic criteria, ideally by a team that can rule out other causes.⁠^1,2

1. Talk to the adults first. Parents and teachers are interviewed without the child present, about whom the child talks to, where and how, and how the silence began.⁠^1,2
2. Rule out hearing loss. A hearing screening checks that hearing loss is not contributing.⁠¹
3. Assess speech and language. Understanding, expression, speech sounds and voice, often using a home video or tests given by a parent the child will talk to.⁠¹
4. Meet the child without pressure. Play-based first sessions with no expectation of speech, and other ways to answer, such as writing, drawing or speaking through a parent.⁠^1,27
5. Check for related conditions. Social and other anxiety disorders, autism, language disorders and, in a bilingual child, whether the silence occurs in every language.⁠¹

A child may not say a word during the assessment, and that is expected: clinicians should be ready to communicate in other ways and to accept information from parents.⁠^2,27

Who diagnoses selective mutism?

Usually a team that can include a pediatrician, a psychologist or psychiatrist and a speech-language pathologist. ASHA says a speech-language pathologist with advanced training may make the diagnosis, but a team diagnosis ensures a full differential diagnosis.⁠¹

Your child’s pediatrician is a good first stop and can refer you to a mental health professional experienced with children.⁠⁴ DrSensory’s therapist directory lists speech therapy clinics if you want a speech and language assessment too.

Other routes to help:

• SAMHSA’s National Helpline, 1-800-662-HELP (4357). A free, confidential treatment referral and information service, open 24/7 in English and Spanish, that refers callers to local treatment, support groups and community organizations.⁠²⁸
• AACAP’s Child and Adolescent Psychiatrist Finder. It lists psychiatrists who have told AACAP they care for children and teens; the listings are self-reported, and AACAP does not endorse them.⁠²⁹
• Your child’s school. Ask the school counselor or psychologist about an evaluation for special education under IDEA or for a Section 504 plan.⁠^30,31
• Your health plan. Call its behavioral health or member services line and ask which child mental health clinicians it covers.

When should you talk to your child’s doctor about selective mutism?

Talk to your child’s doctor if your child has not spoken at preschool or school, or to people outside the family, for more than a month, or if the silence is keeping them from learning, making friends or asking for help.⁠^1,4

Seek help promptly if your child stopped speaking suddenly, or stopped speaking everywhere, especially after a frightening event.⁠^1,2

How is selective mutism treated?

Treatment aims to lower the anxiety around speaking rather than to make the child talk, using gradual behavioral steps with parents and school involved.⁠^1,2 Cognitive behavioral therapy (CBT) is the recommended approach, and treatments other than medication are generally the first choice.⁠^3,32

What happens in behavioral therapy for selective mutism?

Behavioral therapy builds speech in small, planned steps, starting where the child is comfortable and changing one thing at a time.⁠^1,2 The main techniques are these.⁠^1,2

• Stimulus fading. The child talks with a parent when nobody else is present; a new person, such as a teacher, is gradually brought in, and the parent then withdraws.⁠^1,2
• Shaping. Reinforcing each step toward speech, from gestures to eye contact, short words, longer sentences and finally conversation.⁠^1,2
• Graded exposure. Practicing speaking situations from the least to the most frightening; older children may rank situations such as answering the phone or asking a stranger the time.⁠^1,2
• Positive reinforcement. Praise, small rewards or privileges for each agreed step, so that speaking becomes more rewarding than staying silent.⁠¹
• Desensitization. Getting used to other people hearing their voice, through shared voice or video recordings.⁠²

Structured programs combine these techniques. Parent-child interaction therapy adapted for selective mutism builds comfort first and then prompts speech; integrated behavior therapy runs over 24 weeks of a school year; intensive group treatment packs a course into a week, often as a summer camp.⁠¹

How well does treatment for selective mutism work?

Well for many children, though the trials are small. In a 2021 meta-analysis of five randomized trials with 233 children, psychological treatment had a large effect compared with no treatment.⁠³³ A 2023 review of 25 treatment studies found large gains over waitlists for combined behavioral approaches, but called the evidence thin and urged more trials.⁠³²

Face-to-face treatment showed larger gains than web-based treatment in a 2025 meta-analysis of 12 studies with 472 participants.⁠³⁸

Can speech therapy help selective mutism?

Yes, as part of a team. ASHA describes speech-language pathologists as integral to screening, assessing, diagnosing and treating selective mutism, working with psychologists, psychiatrists and the school.⁠¹

A speech-language pathologist can check for speech sound, language or voice difficulties, which can make a child more anxious about talking, and can lead structured programs that move a child from sounds to words to conversation.⁠¹ NHS guidance suggests contacting a speech and language therapy service directly if help is hard to find.⁠² Speech therapy explains what an evaluation involves.

Can occupational therapy help selective mutism?

Not as a treatment for the mutism itself. The treatments studied for selective mutism have been behavioral, mostly combined with work with the adults around the child: of 25 studies in a 2023 review, 72% combined behavioral and what the authors call systems approaches, 76% included education for parents or teachers, and one added a body-oriented psychomotor therapy linked to play therapy.⁠³²

An occupational therapist can still be part of the team when sensory sensitivities or motor delays add to a child’s strain. ASHA describes one developmental approach, DIR Floortime, that uses sensorimotor and play-based activities and often involves co-treatment with an occupational therapist.⁠¹ Ask the treating clinician how any therapy goals fit the speaking plan, and see what occupational therapy works on.

Is medication used for selective mutism?

Sometimes, mainly for older children or when therapy alone has not been enough. A 2016 systematic review found symptom improvement in 66 of 79 children treated with SSRI antidepressants, but only 3 of 10 studies had an unmedicated comparison group and only 2 were double-blind.⁠³⁹

NHS guidance says medicine is mainly appropriate for older children, teenagers and adults whose anxiety has led to depression, and should never replace changes at home and school or behavioral approaches.⁠² In Norway’s registry, 31.5% of young people with selective mutism were prescribed psychiatric medication, mostly in adolescence and most often an SSRI.⁠¹⁶

Antidepressants can increase suicidal thoughts or behavior in some children, teens and young adults under 25, especially in the first weeks or after a dose change, so close monitoring matters.⁠⁴⁰ If your child talks about suicide, use the crisis lines at the top of this page.

Why does pressure to speak make selective mutism worse?

Because pressure raises the anxiety behind the silence. NHS guidance explains that a child pressured to talk feels great relief when the moment passes, which strengthens the belief that talking is a negative experience.⁠²

The same trap works in reverse when adults rescue the child. Speaking for a distressed child is natural, but ASHA notes that it can discourage future attempts and reinforce the avoidance of speaking.⁠¹ Teachers are advised to avoid speaking for the child, explaining away the silences or pressuring the child to speak.⁠¹

What helps instead is a calm, low-pressure approach: allow plenty of time to answer, offer choices rather than open questions, describe what the child is doing instead of asking questions, and accept nonverbal answers for now.⁠^1,2

What is family accommodation in selective mutism?

Family accommodation means the changes parents make to their own behavior and routines to spare an anxious child distress, such as speaking for them.⁠⁴¹ A 2026 study built the first questionnaire for it in speaking situations, with four kinds: speaking for the child, accepting whispers, accepting nonverbal communication, and instrumental accommodation.⁠⁴²

How much accommodation matters in selective mutism is still unclear. In childhood anxiety generally, it is linked to more severe anxiety.⁠⁴¹ In one clinic sample with selective mutism, accommodation was common but did not track the severity of the mutism, while in another, families of children with frequent temper outbursts accommodated most.⁠^43,44

A parent program called SPACE, which teaches parents to reduce accommodation and respond supportively, worked as well as child CBT in a trial of 124 children aged 7 to 14; their primary diagnoses were generalized, social, separation and specific-phobia anxiety disorders, not selective mutism.⁠⁴¹ Ask your child’s therapist how to step back from speaking for your child gradually, as part of the plan.⁠¹

How can parents help a child with selective mutism at home?

Parents are central to treatment, and NHS guidance and ASHA agree on the basics: take the pressure off, keep life going, and notice small steps.⁠^1,2

1. Take the pressure off. Do not pressure or bribe your child to speak; tell them you understand speaking feels hard, that they can take small steps when ready, and that it will get easier.⁠²
2. Accept other ways to communicate. Smiling, waving, nodding and pointing are fine until talking feels easier.⁠²
3. Praise effort, privately. Praise every effort to join in, but not in front of others, and respond warmly, without surprise, when your child does speak.⁠²
4. Keep going to events. Do not avoid parties or family visits; plan changes that make them easier, and ask relatives to let your child warm up at their own pace.⁠²
5. Share the plan. Agree with relatives and the school on one way to respond, since consistency at home and at school matters.⁠¹
6. Record a home video. A video of your child talking at home shows clinicians what they cannot see in the office.⁠¹

Let your child know they will be able to speak when they are ready, and keep the focus on having fun together.⁠²

How can teachers help a child with selective mutism at school?

School is where selective mutism usually shows, so the plan has to reach the classroom. ASHA suggests these strategies for teachers and school staff.⁠¹

• Remember the child understands even when they are not talking, and reassure others of that.⁠¹
• Do not speak for the child, explain away the silence or press for speech.⁠¹
• Let the child take part without speaking at first, through signals, gestures, pictures, writing or a nonverbal classroom job.⁠¹
• Use small, cooperative groups that include the child’s preferred classmates.⁠¹
• Make the same request at the same point in the routine, to reduce anxiety.⁠¹
• Arrange one-to-one time so the child can ask for help quietly, away from classmates.⁠¹
• Reinforce small improvements, and give a newly identified child regular access to someone they can talk to during the day.⁠¹

Children who cannot ask to use the toilet may hold on for hours, and some skip eating and drinking all day, which is worth planning for with the school.⁠²

Is selective mutism a disability?

It can be, for school purposes. There is no single special education category for selective mutism; under IDEA, eligibility can fall under other health impairment, speech or language impairment, or emotional disturbance.⁠^1,30

IDEA’s definition of emotional disturbance includes a tendency to develop fears associated with personal or school problems, present over a long period and to a marked degree, that adversely affects educational performance.⁠³⁰ Section 504 covers a mental impairment that substantially limits a major life activity, and its regulations list both speaking and learning.⁠³¹

Some children need only classroom accommodations through a 504 plan; others need special education services for communication.⁠¹ How to request a school evaluation has a sample letter you can adapt.

Will my child grow out of selective mutism?

Many children improve, but waiting is not a plan. In a school-based study, children with selective mutism improved somewhat over six months but stayed impaired, and the authors concluded that intervention is preferable to waiting for it to go away on its own.⁠¹⁴

With treatment, the outlook is good for most. Across long-term studies in a 2023 review, 190 of 243 children improved moderately or fully, and most recovered during adolescence, though other anxiety disorders were common later.⁠⁹ Five years after CBT, 21 of 30 children were in full remission, though half still found talking outside the home somewhat challenging.⁠³

Starting younger tends to help: older age, more severe mutism and selective mutism in the family predicted poorer outcomes.⁠^3,8 In a follow-up of 33 young adults who had selective mutism as children, the mutism had improved considerably, but phobic disorders were more common than in controls.⁠⁴⁵ Left untreated, selective mutism can lead to isolation, low self-esteem and social anxiety disorder.⁠²

Related on DrSensory

• Social anxiety in children

  Symptoms by age, causes and treatment of social anxiety disorder.

• Generalized anxiety disorder

  Signs by age, causes, screening and treatment of GAD in children.

• Speech therapy

  What speech therapy treats, who it helps and what an evaluation involves.

• Speech and language development

  The difference between speech and language, and milestones by age.

• Autism

  What autism is, how it is diagnosed and what support helps.

• Sensory over-responsivity

  Signs sense by sense, and how sensory overload differs from anxiety.

• Preschool development

  What most children do between three and five, and the signs worth acting on.

• OCD in children

  How OCD shows up in children, and what treatment involves.

• Find a therapist

  Search occupational, physical and speech therapy clinics near you.

Sources

1. American Speech-Language-Hearing Association. Selective Mutism (Practice Portal). Checked October 23, 2026.
   Show the passageHide the passage

   “Selective mutism is a complex anxiety disorder that affects pragmatic language”; “individuals with selective mutism do not elect where to speak but are more comfortable speaking in select situations”. The DSM-5-TR criteria, as the portal gives them: “The child shows consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school), despite speaking in other situations”; “The lack of verbal communication interferes with educational or occupational achievement or with social communication”; “The duration of the mutism is at least 1 month (not limited to the first month of school)”; “The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation”; “The mutism is not better explained by a communication disorder (e.g., childhood-onset fluency disorder) or exclusively due to the presence of autism spectrum disorder, schizophrenia, or another psychotic disorder”. “The onset of selective mutism typically occurs between 3 and 6 years of age, with diagnosis often occurring when the child enters school”; “the three primary factors (i.e., person, place, activity) can trigger a child’s mutism”; “may be mute during specific anxiety-producing activities (e.g., reading out loud, music class)”. “Most prevalence estimates for selective mutism range between 0.2% and 1.6%”; “Prevalence can be somewhat higher among immigrant children, language-minority children, and children with speech and language delays”; “selective mutism must exist in all languages to confirm an accurate diagnosis in these populations”; “most studies report that selective mutism affects more females than males by a ratio of about 1.5–2.5:1.0”, or “that there is no difference between genders”. Signs: “may be interpreted as deliberately oppositional”; “Misunderstanding such behaviors may complicate the identification of selective mutism”; “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)”; “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 be perceived as withdrawn, inattentive, or aloof”; “May use nonverbal methods of communication (e.g., body posture, eye gaze, facial expression, gesture)”; “Unable to initiate using any mode of communication to request help”; associated conditions: “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”. Causes: “No single cause of selective mutism has been identified, and its causes may be multifactorial”; “Hereditary or genetic predisposition of selective mutism and social anxiety disorder”; “Family and environmental factors, such as reduced opportunities for social contact, parenting style, or reinforced avoidance behaviors”; “Neurological/neurodevelopmental vulnerabilities, such as delays in achieving speech, language, or fine and gross motor milestones”; “Overactive autonomic nervous system response that impacts physiological, sensory, and emotional–behavioral responses”; “Other factors, such as shy or timid temperament”. Assessment: “Speech-language pathologists (SLPs) play an integral role in the screening, assessment, diagnosis, and treatment of individuals with selective mutism”; “a diagnosis made by an interdisciplinary team ensures that a full differential diagnosis was completed”; the team “may consist of a pediatrician, a psychologist or psychiatrist, an SLP, a teacher, a school social worker or guidance counselor, and family/care partners”; “If an SLP has advanced training in and knowledge of selective mutism, diagnosis is possible in accordance with existing state credentialing laws”; “hearing screening to rule out hearing loss as a possible contributing factor”; “A diagnostic interview with parents/care partners and teachers is conducted without the child present”; “requesting a video recording of the child’s communicative behavior at home”; “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”; “scheduling two to three sessions for age-appropriate recreational or play-based interactions without the expectation for speech”; “Speech sound disorders may occur in children with selective mutism and may magnify the child’s anxiety of interacting with others”; “Some children with selective mutism have reported that they do not like their voice”; “this speech may be produced in a whisper, at a decreased vocal intensity, or in an altered vocal quality”; “The altered vocal quality can lessen as anxiety decreases”; “Receptive and expressive language skills may vary in children with selective mutism”; “Think aloud by providing behavioral descriptions of what the child is doing, rather than by asking direct questions”; “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”. “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”; selective mutism “may occur simultaneously with” social, generalized and separation anxiety, autism, specific phobia, “obsessive-compulsive disorder” and speech or language disorder; “When children are exposed to a new language, they may experience a brief silent period in which they are quiet and speak little”; “children with typical second-language acquisition demonstrate appropriate social communication skills in settings and with people who speak the child’s primary language”; “Multilingual children with true selective mutism present with mutism in both languages, in several unfamiliar settings, and for significant periods of time”; “Children who do not speak following trauma are mute in all settings”; “If the child spoke well prior to these events, then a diagnosis of selective mutism may not be appropriate”; “referral to a behavioral health professional is appropriate”. School: “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”; “someone who the child can speak to throughout the day”; “The level of accommodations will depend on the functional impact of selective mutism in the school setting”; “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”. Treatment: “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 “may discourage the child’s future speech attempts and results in negatively reinforcing the child’s avoidance of speaking”; “Consistency in the intervention and expectations, at home and in school, of everyone on the team is important”; “Pharmacological treatment may be prescribed by the individual’s treating pediatrician or psychiatrist”; “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”; “changing only one variable at a time”; “Exposure-based practice involves the child saying words in gradually but increasingly difficult or anxiety-provoking situations”; “Stimulus fading involves gradually increasing exposure to a fear-evoking stimulus”; “providing positive reinforcement contingent upon verbalization” and “reinforcing attempts and approximations to communicate (i.e., shaping)”; reinforcements may be “verbal (e.g., praise)”, “tangible (e.g., toys, special outings, belongings)” or privileges; DIR Floortime “incorporates sensorimotor and play-based activities (often having co-treatments with an occupational therapist)”; integrated behavioral therapy “takes place over 24 weeks during the school year”; intensive group treatment can take place in “a 1-week summer camp program”; parent–child interaction therapy for selective mutism “aims to increase verbal interactions in social settings and decrease avoidance behaviors”. For teachers: “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”; “Avoid speaking for the child, justifying the child’s silences, or pressuring the child to speak, all of which may reinforce mutism”; “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”; “Arrange one-on-one time with the teacher and student so that they can seek assistance quietly rather than in front of peers”. “selective mutism in childhood may persist into adolescence and adulthood, or it may develop into another anxiety disorder or phobia”; “The inability to speak may bring about feelings of shame, isolation, frustration, and hopelessness”; ICD-10-CM classifies it “within the ICD-10-CM family of codes for behavioral and emotional disorders with onset usually occurring in childhood and adolescence”.
2. NHS. Selective mutism. Page last reviewed February 17, 2023. Checked October 23, 2026.
   Show the passageHide the passage

   “Selective mutism is an anxiety disorder where a person is unable to speak in certain social situations, such as with classmates at school or to relatives they do not see very often”; “A child or adult with selective mutism does not refuse or choose not to speak at certain times, they’re literally unable to speak”; “The expectation to talk to certain people triggers a freeze response with feelings of anxiety and panic, and talking is impossible”; “Selective mutism affects about 1 in 140 young children. It’s more common in girls and children who have recently migrated from their country of birth”. Signs: “Selective mutism can start at any age, but most often starts in early childhood, between age 2 and 4”; “It’s often first noticed when the child starts to interact with people outside their family, such as when they begin nursery or school”; “a sudden stillness and frozen facial expression when they’re expected to talk to someone who’s outside their comfort zone”; “stubborn or aggressive, having temper tantrums when they get home from school, or getting angry when questioned by parents”; “More confident children with selective mutism can use gestures to communicate”; “But more severely affected children tend to avoid any form of communication – spoken, written or gestured”; “they may speak in an altered voice, such as a whisper”. Causes: “Experts regard selective mutism as a fear (phobia) of talking to certain people”; “If they have a speech and language disorder or hearing problem, it can make speaking even more stressful”; “Some children have trouble processing sensory information such as loud noise and jostling from crowds – a condition known as sensory integration dysfunction”; “This can make them “shut down” and be unable to speak when overwhelmed in a busy environment”; “When mutism occurs as a symptom of post-traumatic stress, it follows a very different pattern and the child suddenly stops talking in environments where they previously had no difficulty”; “Having selective mutism does not mean you’re autistic, as these are two separate conditions. But you can have selective mutism and also be autistic”; “Autism has other signs and symptoms, such as repetitive behaviour and sensory issues, as well as difficulties with communication”. “Left untreated, selective mutism can lead to isolation, low self-esteem and social anxiety disorder”; “Do not accept the opinion that your child will grow out of it”; “speak to a GP and ask them to refer you to a local specialist service for a formal diagnosis”; “You can also contact a speech and language therapy clinic directly”; “Your child may also need to see a mental health professional or school educational psychologist”; “A person with selective mutism may not be able to speak during their assessment, but the clinician should be prepared for this and be willing to find another way to communicate”; “their inability to speak to certain people has lasted for at least 1 month (2 months in a new setting)”; “It’s possible for adults to overcome selective mutism, although they may continue to experience the psychological and practical effects of spending years without social interaction”. “Accidents and urinary infections may result from being unable to ask to use the toilet and holding on for hours at a time”; “School-aged children may avoid eating and drinking throughout the day so they do not need to excuse themselves”; “Children may have difficulty with homework assignments or certain topics because they’re unable to ask questions in class”. Treatment: “With appropriate handling and treatment, most children are able to overcome selective mutism. But the older they are when the condition is diagnosed, the longer it will take”; “Treatment does not focus on the speaking itself, but reducing the anxiety associated with speaking”; “This starts by removing pressure on the person to speak”; “reassuring them that they’ll be able to speak when they’re ready”; “concentrating on having fun”; “praising all efforts the child makes to join in and interact with others, such as passing and taking toys, nodding and pointing”; “not showing surprise when the child speaks, but responding warmly as you would to any other child”; “In stimulus fading, the person with selective mutism communicates at ease with someone, such as their parent, when nobody else is present”; “Another person is gradually introduced into the situation and, once they’re included in talking, the parent withdraws”; shaping moves from “non-verbal communication, gradually moving to making eye contact, saying short words and then longer sentences and, finally, 2-way conversation”; “Older children and adults are encouraged to work out how much anxiety different situations cause, such as answering the phone or asking a stranger the time”; “If the child is under pressure to talk, they’ll experience great relief when the moment passes, which will strengthen their belief that talking is a negative experience”; “Desensitisation is a technique that involves reducing the person’s sensitivity to other people hearing their voice by sharing voice or video recordings”; “Medicine is only really appropriate for older children, teenagers and adults whose anxiety has led to depression and other problems”; “Medicine should never be prescribed as an alternative to environmental changes and behavioural approaches”. Advice for parents: “Do not pressurise or bribe your child to encourage them to speak”; “Tell them they can take small steps when they feel ready and reassure them that talking will get easier”; “Do not praise your child publicly for speaking because this can cause embarrassment”; “Reassure your child that non-verbal communication, such as smiling and waving, is fine until they feel better about talking”; “Do not avoid parties or family visits, but consider what environmental changes are necessary to make the situation more comfortable for your child”; “Ask friends and relatives to give your child time to warm up at his or her own pace”.
3. Oerbeck B, Overgaard KR, Stein MB, Pripp AH, Kristensen H. Treatment of selective mutism: a 5-year follow-up study. European Child & Adolescent Psychiatry. 2018;27(8):997–1009. doi:10.1007/s00787-018-1110-7 (PMID 29357099; PMC6060963). Checked October 23, 2026.
   Show the passageHide the passage

   “Cognitive behavioral therapy (CBT) is the recommended approach for SM”; “we provide 5-year outcome data for 30 of these 32 children with SM who completed the same CBT” “at mean age 6 years”; “At the 5-year follow-up, 21 children were in full remission, five were in partial remission and four fulfilled diagnostic criteria for SM”; “Seven children (23%) fulfilled criteria for social phobia”; “Older age and severity at baseline and familial SM were significant negative predictors of outcome”; “Although most of them talked outside of home, 50% still experienced it as somewhat challenging”.
4. National Institute of Mental Health. Children and Mental Health: Is This Just a Stage?. Checked October 23, 2026.
   Show the passageHide the passage

   “Consider seeking help if your child’s behavior or emotions last for weeks or longer, cause distress for your child or your family, or interfere with your child’s functioning at school, at home, or with friends”; “You can talk with your child’s pediatrician or health care provider and describe your child’s behavior” and “ask the health care provider for a referral to a mental health professional with experience and expertise in evaluating and treating children”. “call or text the 988 Suicide & Crisis Lifeline at 988 or chat at 988lifeline.org”. “In life-threatening situations, call 911”.
5. Crisis Text Line. Crisis Text Line | Text HOME to 741741 Free, 24/7 Mental Health Support. “Text HOME to 741741 from anywhere in the United States – 24/7, free, confidential”; “A live, trained volunteer Crisis Counselor will receive your text and respond with care and compassion”. Checked October 23, 2026.
6. Driessen J, Blom JD, Muris P, Blashfield RK, Molendijk ML. Anxiety in children with selective mutism: a meta-analysis. Child Psychiatry & Human Development. 2020;51(2):330–341. doi:10.1007/s10578-019-00933-1 (PMID 31650460; PMC7067754). Checked October 23, 2026.
   Show the passageHide the passage

   “On the basis of 22 eligible studies (N = 837), we found that 80% of the children with SM were diagnosed with an additional anxiety disorder, notably social phobia (69%)”; “This was followed by specific phobia (19%), separation anxiety disorder (18%), generalized anxiety disorder (6%), and obsessive-compulsive disorder (6%)”; “it remains unclear how anxiety is manifested in the remaining 20% of the children that lacked such an additional diagnosis”. History: Kussmaul’s “1877 pioneering work on speech disturbances offered several clinical descriptions of “absence of speech without disturbance of speech”, a condition he associated primarily with cases of “hysteria and other neuroses””; “a subtle yet oft-repeated misconception has been that Kussmaul called this condition ‘aphasia voluntaria’ (i.e., ‘voluntary inability to speak’), a malapropism of the term ‘aphrasia voluntaria’ that he actually used, which has the more plausible meaning of a ‘voluntary absence of speech’”; “In 1934 another pioneer in the area of speech disorders, the Swiss child psychiatrist Tramer (1882–1963), suggested elektiver Mutismus as an appropriate term”; “In Tramer’s view, children with this diagnosis are not aphasic, but deliberately choose to remain silent”; “the DSM Task Force for DSM-IV decided to replace ‘Elective Mutism’ by ‘Selective Mutism’ (SM), thus expressing the notion that this type of mutism is found in specific contexts rather than being (necessarily) self-chosen”; “the plan to reclassify SM as an anxiety disorder was effectuated in the DSM-5”.
7. Black B, Uhde TW. Psychiatric characteristics of children with selective mutism: a pilot study. Journal of the American Academy of Child & Adolescent Psychiatry. 1995;34(7):847–856. doi:10.1097/00004583-199507000-00007 (PMID 7649954). Checked October 23, 2026.
   Show the passageHide the passage

   “Thirty children were evaluated”; “Ninety-seven percent of the subjects were diagnosed with social phobia or avoidant disorder of childhood or adolescence or both”; “First-degree family history of social phobia and of selective mutism, obtained by family history method, was present in 70% and 37% of families, respectively”; “There was no evidence of a causal relationship between psychologically or physically traumatic experiences and development of selective mutism”.
8. Oerbeck B, Stein MB, Pripp AH, Kristensen H. Selective mutism: follow-up study 1 year after end of treatment. European Child & Adolescent Psychiatry. 2015;24(7):757–766. doi:10.1007/s00787-014-0620-1 (PMID 25267381; PMC4490179). Checked October 23, 2026.
   Show the passageHide the passage

   “outcome data 1 year after having completed the 6-month course of CBT for 24 children with SM, aged 3-9 years”; the abstract: “Younger children improved more, as 78% of the children aged 3-5 years did not have SM, compared with 33% of children aged 6-9 years”.
9. Koskela M, Ståhlberg T, Yunus WMAWM, Sourander A. Long-term outcomes of selective mutism: a systematic literature review. BMC Psychiatry. 2023;23(1):779. doi:10.1186/s12888-023-05279-6 (PMID 37875905; PMC10598940). Checked October 23, 2026.
   Show the passageHide the passage

   “The review found that 190 of the 243 subjects in the studies that reported recovery rates showed moderate or total improvement from SM during follow up”; “Most subjects with SM recovered from this disorder during adolescence, but anxiety disorders were common in later life”; depressive and psychotic symptoms “were found only in a couple of studies, but this was probably because half of the studies only followed up subjects during childhood”; “A 2021 paper by Rødgaard reported that 1% of 2,199 children with autism had received a diagnosis of SM in childhood, compared to none of the 460,798 controls”.
10. Muris P, Ollendick TH. Children who are anxious in silence: a review on selective mutism, the new anxiety disorder in DSM-5. Clinical Child and Family Psychology Review. 2015;18(2):151–169. doi:10.1007/s10567-015-0181-y (PMID 25724675). Checked October 23, 2026.
    Show the passageHide the passage

    “The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists SM among the anxiety disorders”; “At the same time, critical points can be raised regarding the classification of SM as an anxiety disorder”.
11. Hua A, Major N. Selective mutism. Current Opinion in Pediatrics. 2016;28(1):114–120. doi:10.1097/MOP.0000000000000300 (PMID 26709680). Checked October 23, 2026.
    Show the passageHide the passage

    “These findings have led to the recent reclassification of selective mutism as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition”; other factors include “communication delays and immigration/bilingualism”; “The development of selective mutism appears to result from the interplay of a variety of genetic, temperamental, environmental, and developmental factors”; “several randomized studies have supported the efficacy of psychosocial interventions based on a graduated exposure to situations requiring verbal communication”.
12. World Health Organization. 6B06 Selective mutism. ICD-11 for Mortality and Morbidity Statistics, release 2026-01. The release’s tabulation lists 6B06 “Selective mutism” in the block “Anxiety or fear-related disorders”. Checked October 23, 2026.
13. National Library of Medicine, Clinical Table Search Service. ICD-10-CM codes F94.0 to F94.9. F94.0 “Selective mutism”; F94.1 “Reactive attachment disorder of childhood”; F94.2 “Disinhibited attachment disorder of childhood”; F94.8 “Other childhood disorders of social functioning”; F94.9 “Childhood disorder of social functioning, unspecified”. Checked October 23, 2026.
14. Bergman RL, Piacentini J, McCracken JT. Prevalence and description of selective mutism in a school-based sample. Journal of the American Academy of Child & Adolescent Psychiatry. 2002;41(8):938–946. doi:10.1097/00004583-200208000-00012 (PMID 12162629). Checked October 23, 2026.
    Show the passageHide the passage

    “Kindergarten, first, and second grade teachers in a large district were asked to identify pupils who met DSM-IV criteria for SM”; “the prevalence of SM was .71% (16/2,256)”; “As a group, children with SM had improved 6 months later but remained impaired and symptomatic when compared with the comparison group”; “SM may not be as rare as previously thought”; “intervention is preferable to waiting for SM to remit spontaneously”.
15. Elizur Y, Perednik R. Prevalence and description of selective mutism in immigrant and native families: a controlled study. Journal of the American Academy of Child & Adolescent Psychiatry. 2003;42(12):1451–1459. doi:10.1097/00004583-200312000-00012 (PMID 14627880). In “West Jerusalem’s state preschools”: “The general prevalence of SM was 0.76%, while the rate among immigrants was 2.2%”. Checked October 23, 2026.
16. Oerbeck B, Manassis K, Kristensen H, Overgaard KR. Youth with selective mutism: a nationwide patient registry study. European Child & Adolescent Psychiatry. 2026 (online ahead of print). doi:10.1007/s00787-026-03211-3 (PMID 42853409). Checked October 23, 2026.
    Show the passageHide the passage

    “The sample comprised all youth referred to CAMHS and registered with a diagnosis of SM in the Norwegian Patient Registry from 2008 to 2022”; “In total, 1591 youth with SM were identified, with a female-to-male ratio of 2:1”; “The mean age at SM diagnosis was 10.1 years”; “Additional mental disorders were diagnosed in 51.4%”; “Nearly one-third (31.5%) were prescribed psychotropic medication, mainly during adolescence, with selective serotonin reuptake inhibitors (SSRIs) being most common”.
17. Steffenburg H, Steffenburg S, Gillberg C, Billstedt E. Children with autism spectrum disorders and selective mutism. Neuropsychiatric Disease and Treatment. 2018;14:1163–1169. doi:10.2147/NDT.S154966 (PMID 29765220; PMC5944454). Checked October 23, 2026.
    Show the passageHide the passage

    “we examined medical records of children with SM diagnosis (n=97) at a medical center specializing in assessment of ASD”; “Mean age for onset of SM symptoms was 4.5 years and mean age at SM diagnosis was 8.8 years”; “We found that 63% of the study group had an ASD (no gender difference)”; “The SM group with combined ASD had later onset of symptoms, higher age at diagnosis, more often a history of speech delay”.
18. de Jong R, van der Voort A, Aben W, de Jonge MV. Understanding silence in adolescence and young adulthood: a mixed methods systematic review on selective mutism. European Child & Adolescent Psychiatry. 2026;35(5):1415–1434. doi:10.1007/s00787-025-02951-y (PMID 41718813; PMC13272219). Checked October 23, 2026.
    Show the passageHide the passage

    “individuals between 10-24 years old with a current diagnosis of SM”; “40 studies (n = 54 participants) met inclusion criteria”; “adolescents and young adults with SM have a later onset, longer diagnostic delays, and a prolonged history of negative reinforcement of symptoms from accommodations by others”; “Consequently, SM tends to be more therapy-resistant”.
19. Chavira DA, Shipon-Blum E, Hitchcock C, Cohan S, Stein MB. Selective mutism and social anxiety disorder: all in the family?. Journal of the American Academy of Child & Adolescent Psychiatry. 2007;46(11):1464–1472. doi:10.1097/chi.0b013e318149366a (PMID 18049296). Checked October 23, 2026.
    Show the passageHide the passage

    “Lifetime generalized social phobia was present in 37.0% of SM parents compared to 14.1% of control parents”; “These results support earlier uncontrolled findings of a familial relationship between generalized social phobia and SM”.
20. Kristensen H. Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder, and elimination disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 2000;39(2):249–256. doi:10.1097/00004583-200002000-00026 (PMID 10673837). Checked October 23, 2026.
    Show the passageHide the passage

    “A total of 54 children with SM and 108 control children were evaluated”; “Of the children with SM, 68.5% met the criteria for a diagnosis reflecting developmental disorder/delay compared with 13.0% in the control group”; “The criteria for any anxiety diagnosis were met by 74.1% in the SM group and for an elimination disorder by 31.5% versus 7.4% and 9.3%, respectively, in the control group”; “The mutism may conceal developmental problems in children with SM”.
21. Koskela M, Chudal R, Luntamo T, Suominen A, Steinhausen HC, Sourander A. The impact of parental psychopathology and sociodemographic factors in selective mutism: a nationwide population-based study. BMC Psychiatry. 2020;20(1):221. doi:10.1186/s12888-020-02637-6 (PMID 32398046; PMC7216734). Checked October 23, 2026.
    Show the passageHide the passage

    “This nested case-control study comprised 860 cases with SM, identified from the Finnish Hospital Discharge Register and 3250 controls”; “If both parents had any psychiatric disorder, this almost tripled their odds of having a child with SM (OR 2.8, 95% CI 2.0-4.0)”.
22. Gudrunardottir T, Morgan AT, Lux AL, et al. Consensus paper on post-operative pediatric cerebellar mutism syndrome: the Iceland Delphi results. Child’s Nervous System. 2016;32(7):1195–1203. doi:10.1007/s00381-016-3093-3 (PMID 27142103). On “post-operative mutism and associated morbidity in pediatric patients with cerebellar tumors”: “A new, proposed definition of “post-operative pediatric CMS” was formed”. Checked October 23, 2026.
23. Muris P, Ollendick TH. Selective mutism and its relations to social anxiety disorder and autism spectrum disorder. Clinical Child and Family Psychology Review. 2021;24(2):294–325. doi:10.1007/s10567-020-00342-0 (PMID 33462750; PMC8131304). “we point out that autism spectrum problems in addition to anxiety problems are sometimes also implicated in SM”. Checked October 23, 2026.
24. Oerbeck B, Kristensen H. Attention in selective mutism – an exploratory case-control study. Journal of Anxiety Disorders. 2008;22(3):548–554. doi:10.1016/j.janxdis.2007.04.008 (PMID 17531438). Checked October 23, 2026.
    Show the passageHide the passage

    “a clinical sample of 23 children with SM (aged 7-16 years, 12 boys and 11 girls) and 46 non-referred matched controls”; “The SM group differed from controls on the Trail Making Test, but the group difference disappeared, when controlling for motor function and IQ”.
25. Ludlow AK, Osborne C, Keville S. Selective mutism in children with and without an autism spectrum disorder: the role of sensory avoidance in mediating symptoms of social anxiety. Journal of Autism and Developmental Disorders. 2023;53(10):3891–3900. doi:10.1007/s10803-022-05674-0 (PMID 35904647). Checked October 23, 2026.
    Show the passageHide the passage

    “Seventy-five parents completed an online composite questionnaire”; “the SM + ASD group showed significantly higher levels of social anxiety and sensory avoidance compared to the SM only group”; “a simple mediation model revealed sensory avoidance to be a mediator of this relationship between the diagnosis and social anxiety”.
26. Muris P, Voermans L, Paes L, Langen I, Sollman E. Correlates of selective mutism in young children: a preliminary investigation of social anxiety, autistic traits, extreme demand avoidance, and sensory processing sensitivity. Clinical Child Psychology and Psychiatry. 2026 (online ahead of print). doi:10.1177/13591045261487890 (PMID 42721457). Checked October 23, 2026.
    Show the passageHide the passage

    A “parent-report survey study” of 3- to 6-year-olds: “children with SM displayed significantly higher levels of social anxiety, autistic traits, extreme demand avoidance, and sensory processing sensitivity than their non-clinical counterparts”.
27. National Institute for Health and Care Excellence. Social anxiety disorder: recognition, assessment and treatment (CG159), Recommendations. Published May 22, 2013. Checked October 23, 2026.
    Show the passageHide the passage

    “children with a potential diagnosis of selective mutism may be unable to speak at all during assessment or treatment”; “accept information from parents or carers, but ensure that the child or young person is given the opportunity to answer for themselves, through writing, drawing or speaking through a parent or carer if necessary”.
28. Substance Abuse and Mental Health Services Administration. SAMHSA’s National Helpline. “SAMHSA’s National Helpline is a free, confidential, 24/7, 365-day-a-year treatment referral and information service (in English and Spanish) for individuals and families facing mental and/or substance use disorders”; “1-800-662-HELP (4357)”; “This service provides referrals to local treatment facilities, support groups, and community-based organizations”. Checked October 23, 2026.
29. American Academy of Child and Adolescent Psychiatry. Child and Adolescent Psychiatrist Finder. Checked October 23, 2026.
    Show the passageHide the passage

    The finder is “designed to help parents and other adults who are seeking psychiatric care for their children to locate psychiatrists who have reported to AACAP that they are providers of psychiatric care for children and adolescents”; “The information available through the Psychiatrist Finder is self-reported by AACAP members”; “AACAP does not give endorsements or recommendations concerning any particular psychiatrists”.
30. Individuals with Disabilities Education Act regulations, Electronic Code of Federal Regulations. 34 CFR § 300.8 Child with a disability. Checked October 23, 2026.
    Show the passageHide the passage

    Paragraph (a)(1): “Child with a disability means a child evaluated in accordance with §§ 300.304 through 300.311”; paragraph (c)(4): emotional disturbance means “a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s educational performance”, including “A tendency to develop physical symptoms or fears associated with personal or school problems”; paragraph (c)(11): “Speech or language impairment means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance”.
31. Section 504 regulations, Electronic Code of Federal Regulations. 34 CFR § 104.3 Definitions. Checked October 23, 2026.
    Show the passageHide the passage

    Paragraph (j), “Handicapped person” (the regulation’s own term for a person with a disability): “has a physical or mental impairment which substantially limits one or more major life activities”; “Major life activities means functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working”.
32. Hipolito G, Pagnamenta E, Stacey H, Wright E, Joffe V, Murayama K, Creswell C. A systematic review and meta-analysis of nonpharmacological interventions for children and adolescents with selective mutism. JCPP Advances. 2023;3(3):e12166. doi:10.1002/jcv2.12166 (PMID 37720585; PMC10501694). Checked October 23, 2026.
    Show the passageHide the passage

    “Nonpharmacological interventions are commonly seen as the preferred first treatment”; “Twenty-five studies were identified”; “Three studies compared a combined systems/behavioural approach with waitlist controls indicating a significant and large effect”; “Eighteen studies (72%) used a combined behavioural and systems approach”; “psychoeducation for parents and/or teachers (k = 19, 76%)”; one study “closely linked to play therapy (psychomotor therapy)”; “there has been little systematic evaluation of non-pharmacological interventions”; “further systematic evaluations are urgently needed”.
33. Steains SY, Malouff JM, Schutte NS. Efficacy of psychological interventions for selective mutism in children: a meta-analysis of randomized controlled trials. Child: Care, Health and Development. 2021;47(6):771–781. doi:10.1111/cch.12895 (PMID 34265102). Checked October 23, 2026.
    Show the passageHide the passage

    “Five RCTs with a total of 233 participants were analysed using a random-effects model”; “The results of the analyses showed psychological interventions to be more effective than no treatment, with the overall weighted effect size of g = 0.87, indicating a large mean treatment effect”.
34. Bergman RL, Gonzalez A, Piacentini J, Keller ML. Integrated Behavior Therapy for Selective Mutism: a randomized controlled pilot study. Behaviour Research and Therapy. 2013;51(10):680–689. doi:10.1016/j.brat.2013.07.003 (PMID 23933108). Checked October 23, 2026.
    Show the passageHide the passage

    “A total of 21 children ages 4 to 8 with primary selective mutism were randomized to 24 weeks of Integrated Behavior Therapy for Selective Mutism (IBTSM) or a 12-week Waitlist control”; “a high rate of treatment responders as rated by blind independent evaluators (75%)”; “Clinical gains were maintained over 3 month follow-up”.
35. Oerbeck B, Stein MB, Wentzel-Larsen T, Langsrud Ø, Kristensen H. A randomized controlled trial of a home and school-based intervention for selective mutism: defocused communication and behavioural techniques. Child and Adolescent Mental Health. 2014;19(3):192–198. doi:10.1111/camh.12045 (PMID 32878377). Checked October 23, 2026.
    Show the passageHide the passage

    “Overall, 24 children with SM, aged 3-9 years, were randomized to 3 months treatment (n = 12) or wait list (n = 12)”; “significantly increased speech in the treatment group”; “Greater improvement in the younger age group highlights the importance of an early intervention”.
36. Cornacchio D, Furr JM, Sanchez AL, et al. Intensive group behavioral treatment (IGBT) for children with selective mutism: a preliminary randomized clinical trial. Journal of Consulting and Clinical Psychology. 2019;87(8):720–733. doi:10.1037/ccp0000422 (PMID 31294589; PMC6629469). Checked October 23, 2026.
    Show the passageHide the passage

    “Twenty-nine children with SM (5-9 years; 76% female; 35% ethnic minority) were randomized to immediate SM 5-day IGBT or to a 4-week waitlist”; “At Week 4, 50% of the immediate IGBT condition and 0% of the WLP condition were classified as” clinical responders; “Eight weeks into the following school year, 46% of IGBT-treated children were free of an SM diagnosis”.
37. Catchpole R, Young A, Baer S, Salih T. Examining a novel, parent child interaction therapy-informed, behavioral treatment of selective mutism. Journal of Anxiety Disorders. 2019;66:102112. doi:10.1016/j.janxdis.2019.102112 (PMID 31351241). Checked October 23, 2026.
    Show the passageHide the passage

    “Children aged 4-10 with a primary diagnosis of SM were eligible to participate”; “31 families consented”; children “were waitlisted for an average of 4 months before receiving 16 sessions of weekly therapy”; “Results showed significant and large (Cohen’s d = 1.80) gains in speaking behaviors across contexts from pre- to post-treatment”; “Gains were maintained at 3-months and 1-year post-treatment”.
38. Iimura D, Tsujita N, Aoki M, Hagihara H. Meta-analysis of behavioral treatments for selective mutism: findings from selective mutism questionnaire (SMQ) and school speech questionnaire (SSQ). Child and Adolescent Psychiatry and Mental Health. 2025;19(1):40. doi:10.1186/s13034-025-00891-8 (PMID 40181492; PMC11969985). “We analyzed 12 articles involving 472 participants”; “web-based treatment demonstrated less improvement” than face-to-face treatment. Checked October 23, 2026.
39. Manassis K, Oerbeck B, Overgaard KR. The use of medication in selective mutism: a systematic review. European Child & Adolescent Psychiatry. 2016;25(6):571–578. doi:10.1007/s00787-015-0794-1 (PMID 26560144). Checked October 23, 2026.
    Show the passageHide the passage

    “Symptomatic improvement was found for 66/79 children treated with SSRIs”; “Only 3/10 studies had unmedicated comparison groups and only two were double-blinded”; “Although there is some evidence for symptomatic improvement in SM with medication, especially SSRIs, it is limited by small numbers, lack of comparative trials, lack of consistent measures, and lack of consistent reporting on tolerability”.
40. National Institute of Mental Health. Mental Health Medications. Checked October 23, 2026.
    Show the passageHide the passage

    “In some cases, children, teenagers, and young adults under 25 may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting the medication or when the dose is changed”; “People of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment”.
41. Lebowitz ER, Marin C, Martino A, Shimshoni Y, Silverman WK. Parent-based treatment as efficacious as cognitive-behavioral therapy for childhood anxiety: a randomized noninferiority study of supportive parenting for anxious childhood emotions. Journal of the American Academy of Child & Adolescent Psychiatry. 2020;59(3):362–372. doi:10.1016/j.jaac.2019.02.014 (PMID 30851397; PMC6732048). Checked October 23, 2026.
    Show the passageHide the passage

    The article’s Introduction: “Family accommodation refers to the myriad changes in parental behaviors and routines intended to help a child avoid or alleviate anxiety-related distress”; “family accommodation is linked to more severe child anxiety and greater functional impairment”; examples include “speaking for a child with social phobia”. The abstract: “Participants were children with primary anxiety disorders (N = 124; 7-14 years of age”; “SPACE was noninferior, relative to CBT, on primary and secondary anxiety outcomes”. The article’s Method section (Participants): “Primary anxiety diagnoses were: generalized anxiety disorder (35.2%), social phobia (34.8%), separation anxiety disorder (18.2%), specific phobia (11.8%)”.
42. Kamenetskiy A, Furr JM, Herrera A, Feinberg L, Merson RA, Pincus DB, Comer JS. Family accommodation and selective mutism: evaluating the Survey of Accommodation in Verbal Encounters (SAVE). Child Psychiatry & Human Development. 2026 (online ahead of print). doi:10.1007/s10578-026-02081-9 (PMID 42640522). Checked October 23, 2026.
    Show the passageHide the passage

    “research on accommodation specific to childhood selective mutism (SM) is limited and inconsistent”; “In a sample of 412 treatment-seeking anxious youth ages 2-18 years (52.7% with SM”; “four SAVE subscales: Surrogate Speaking, Permitting of Whispered Communication, Permitting of Nonverbal Communication, and Instrumental Accommodation”; “the first measure of parental accommodation in contexts in which child speech is expected”.
43. Fisher J, Wadkins MJ, Kurtz S. Family accommodation in selective mutism: prevalence, relationship to symptom severity, and issues in measurement/assessment. Child Psychiatry & Human Development. 2025 (online ahead of print). doi:10.1007/s10578-025-01876-6 (PMID 40586947). Checked October 23, 2026.
    Show the passageHide the passage

    “accommodation in the SM sample was prevalent, however reported at a lower frequency and with lower levels of parental distress than expected”; “no correlation was found between accommodation and SM symptom severity”.
44. Freitag GF, Coxe S, Cardinale EM, Furr JM, Herrera A, Comer JS. Phasic versus tonic irritability and associations with family accommodation among youth with selective mutism: a latent profile analysis. Research on Child and Adolescent Psychopathology. 2024;52(6):905–917. doi:10.1007/s10802-023-01161-x (PMID 38270833). Checked October 23, 2026.
    Show the passageHide the passage

    “phasic irritability (i.e., temper outbursts) appearing particularly linked with increased family accommodation and overall global impairment”.
45. Steinhausen HC, Wachter M, Laimböck K, Metzke CW. A long-term outcome study of selective mutism in childhood. Journal of Child Psychology and Psychiatry. 2006;47(7):751–756. doi:10.1111/j.1469-7610.2005.01560.x (PMID 16790010). Checked October 23, 2026.
    Show the passageHide the passage

    “A sample of 33 young adults with SM in childhood and two age- and gender-matched comparison groups were studied”; “The symptoms of SM improved considerably in the entire SM sample”; “both SM and ANX had significantly higher rates for phobic disorder and any psychiatric disorder than controls at outcome”.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider about your child. If you are worried about immediate safety, call or text 988 (US). Never start, stop, or change a dose without medical guidance. If your child has lost skills they previously had, contact their doctor promptly.