By Dr. Elisa Shipon Blum 

The SMart Center provides effective and evidence-based assessments and treatment recommendations for individuals who may have Autism Spectrum Disorder (ASD).  And since many of our clients have Selective Mutism. We can accurately differentiate between SM, ASD and determine if a client has both SM and ASD.  Our expertise in SM, allows us to accommodate the individuals mutism to get more accurate testing results.

Our team performs comprehensive evaluations to better understand the person’s functioning, build upon their strengths and provide them with the appropriate supports.  The Clinicians at the SMart Center utilize the Autism Diagnostic Observation Schedule-2 (ADOS-2) as well as the Autism Diagnostic Interview (ADI-R) which are considered to be the ‘gold standard’ for diagnosing Autism. The ASD testing consists of two sessions: 1) Session One is a 2 ½-3 hour interview with the adult requesting testing or the client’s caregiver (specifically someone who is able to provide information about the client’s first 5 years of development), 2) Session Two is an hour long assessment with the child/adolescent/adult. At the conclusion of the testing, the evaluator will develop a comprehensive report based upon the findings from the testing period. The evaluator will schedule a feedback session with the caregiver and the client which will review the results of the testing, diagnostic information, and specific-individualized recommendations that will provide the child/adolescent with the most effective strategies and resources for support.

Comprehensive Autism Spectrum Disorder (ASD) Evaluation

Children, Teens & Adults

A comprehensive Autism Spectrum Disorder (ASD) evaluation is designed to determine whether a child, teen, or adult meets diagnostic criteria for Autism Spectrum Disorder and to develop a deeper understanding of the individual’s social communication, social interaction, behavior, developmental history, strengths, and areas of challenge.

For individuals with Selective Mutism (SM), this type of evaluation can be especially important. Selective Mutism affects social communication, but not every social or communication difficulty experienced by an individual with SM is necessarily caused by anxiety or Selective Mutism.

Some children, teens, and adults with SM also demonstrate differences in social reciprocity, pragmatic language, flexibility, sensory processing, understanding social cues, peer relationships, executive functioning, or other areas of development. The important question becomes:

Is this Selective Mutism? Autism? Social (Pragmatic) Communication Disorder? Anxiety? Or are several factors occurring together?

At the SMart Center, our goal is to understand the “WHYs” behind an individual’s social communication challenges, rather than assuming that every difficulty is simply part of Selective Mutism.

Selective Mutism and Autism Can Look Similar

There can be significant overlap in how Selective Mutism, social anxiety, and Autism Spectrum Disorder appear on the surface. For example, an individual with SM may:

  • Avoid or have difficulty with eye contact
  • Have limited verbal interaction with unfamiliar people
  • Struggle to initiate conversation
  • Give brief or limited responses
  • Have difficulty joining peers or groups
  • Appear socially withdrawn
  • Depend on familiar people to facilitate interaction
  • Have difficulty demonstrating reciprocal conversation
  • Become overwhelmed in busy social environments
  • Have sensory sensitivities
  • Prefer predictability and familiar routines
  • Have difficulty communicating when social demands increase

However, the reason behind these behaviors matters.

A child with SM may have strong age-appropriate social understanding and reciprocity when comfortable but be unable to demonstrate these abilities when anxious. Another child may become verbal when comfortable, yet still have difficulty with conversational reciprocity, perspective-taking, understanding social cues, flexibility, or navigating peer relationships.

And some individuals may have both Selective Mutism and Autism Spectrum Disorder. This is why careful differential diagnosis is so important.

Looking at the Child Beyond Whether They Speak

One of the challenges in evaluating an individual with Selective Mutism is that limited speech during an assessment can make it difficult to determine what the person truly understands and is capable of doing socially.

Therefore, we do not evaluate autism simply by asking: “Did this child talk during the evaluation?”

We look much deeper. We examine how the individual:

  • Connects and engages with others
  • Initiates interaction
  • Responds socially, verbally and nonverbally
  • Shares enjoyment and interests
  • Uses gestures, facial expressions, and body language
  • Demonstrates social reciprocity
  • Understands social cues
  • Navigates conversational give-and-take
  • Understands another person’s perspective
  • Develops and maintains relationships
  • Adjusts communication according to the person and situation
  • Demonstrates flexibility
  • Responds to changes and unexpected situations
  • Experiences sensory input
  • Functions when comfortable compared with when anxious

Understanding the difference between “can’t demonstrate this because of anxiety” and “has an underlying difficulty with this skill” can be essential.

Gold-Standard Autism Assessment Measures

Our comprehensive ASD evaluations incorporate two of the most widely recognized and extensively studied diagnostic instruments in autism assessment: the Autism Diagnostic Observation Schedule (ADOS-2) and, when appropriate, the Autism Diagnostic Interview–Revised (ADI-R).

These measures provide complementary information.

Autism Diagnostic Observation Schedule (ADOS-2)

The ADOS-2 provides structured opportunities for the evaluator to directly observe social communication, interaction, reciprocity, verbal and nonverbal communication, shared enjoyment, flexibility, imagination, and behaviors associated with autism. For an individual with Selective Mutism, ADOS findings must be interpreted within the context of the person’s anxiety and communication level during the assessment.

Limited speech alone does not indicate autism.

The evaluator considers how the individual communicates and connects, including nonverbal communication, social engagement, reciprocity, gestures, facial expression, shared enjoyment, and other behaviors that can be observed even when verbal communication is limited.

Autism Diagnostic Interview–Revised (ADI-R)

The ADI-R provides an in-depth developmental history, generally through an interview with a parent or caregiver familiar with the individual’s early development.

For individuals with SM, developmental history is particularly valuable because it allows us to look beyond what happens during an anxiety-provoking evaluation. We can ask:

What does this person look like when they are comfortable?

How have they historically interacted with family members, peers, and familiar adults? Were social-communication differences present before the Selective Mutism became apparent? Do social difficulties remain even in environments where the individual is comfortable and verbal?

This information can be extremely helpful when differentiating anxiety-based communication inhibition from broader developmental social-communication differences.

Social Communication & Social Pragmatics

An important part of the evaluation is examining not simply whether an individual speaks, but how they use communication socially when they are able to communicate. Assessment may examine:

  • Initiating and maintaining conversations
  • Reciprocal conversation
  • Staying on topic
  • Asking follow-up questions
  • Conversational give-and-take
  • Adjusting communication for different people and situations
  • Understanding implied or nonliteral language
  • Recognizing social cues
  • Perspective-taking
  • Understanding others’ intentions
  • Using and interpreting facial expressions, gestures, tone of voice, and body language
  • Developing and maintaining peer relationships
  • Joining groups
  • Understanding unwritten social expectations

This distinction is especially important in Selective Mutism. An individual may become fully verbal with a familiar person yet continue to demonstrate significant difficulty with the social use of language.

Conversely, another individual may demonstrate excellent social reciprocity, humor, perspective-taking, and conversational skills when comfortable but lose access to those abilities when anxiety becomes too high.

These are very different clinical pictures.

Autism vs. Selective Mutism vs. Social (Pragmatic) Communication Disorder

Differential diagnosis is an important component of the evaluation.

Selective Mutism

With SM, social communication is significantly affected by anxiety and varies according to the person, place, and situation. The individual may demonstrate substantially stronger communication and social abilities when comfortable.

Autism Spectrum Disorder

With ASD, social-communication and social-interaction differences are broader developmental characteristics and are accompanied by restricted or repetitive patterns of behavior, interests, activities, or sensory features required for the diagnosis.

Social (Pragmatic) Communication Disorder

An individual with Social (Pragmatic) Communication Disorder may demonstrate significant difficulty with reciprocal communication, conversation, social understanding, and the social use of language without demonstrating the restricted or repetitive behavior pattern required for an autism diagnosis.

And Sometimes They Coexist

These conditions are not always mutually exclusive. An individual may have Selective Mutism and Autism Spectrum Disorder.

They may have Selective Mutism with ADHD or executive-function challenges. They may have SM with language, learning, processing, or social-pragmatic difficulties. They may have several interacting factors affecting social communication.

The purpose of the evaluation is to determine the combination of factors that best explains the individual’s presentation.

Understanding the “WHYs” Behind Social Communication

At the SMart Center, one of our primary goals is to understand why communication is difficult for this particular person. Consider two children who both remain silent in the classroom.

One child may desperately want to participate and have strong social understanding but become unable to speak because of overwhelming social communication anxiety.

Another may have SM but also struggle to recognize when to enter a conversation, understand peer dynamics, maintain reciprocal interaction, or know what to say. Another may become verbal once comfortable but continue to remain on the outskirts of peer interactions. Another may have sensory sensitivities, rigid thinking, executive-function challenges, or difficulty coping with unpredictable social situations.

They may all appear “quiet” at school. But they do not necessarily have the same WHY.

And therefore, they should not necessarily have the same treatment plan.

Considering Co-Occurring Conditions

A comprehensive evaluation also considers conditions that may occur alongside or contribute to the individual’s presentation, including:

  • Selective Mutism
  • Social anxiety and other anxiety disorders
  • ADHD
  • Executive-functioning difficulties
  • Social (Pragmatic) Communication Disorder
  • Language differences
  • Learning differences
  • Sensory differences
  • Other developmental or psychological conditions

This is particularly important for individuals with Selective Mutism because anxiety, attention, processing, sensory, developmental, and social-pragmatic differences can interact and influence how an individual communicates.

What You Receive

Following the evaluation, all information is integrated to develop a comprehensive picture of the individual rather than relying on a single test, score, or observation. The evaluation typically includes a detailed feedback session and comprehensive written report outlining:

  • ADOS findings and interpretation
  • ADI-R developmental findings, when administered
  • Social-communication and pragmatic-language profile
  • Selective Mutism and anxiety considerations
  • Behavioral and developmental observations
  • Individual strengths and areas of need
  • Diagnostic impressions, when appropriate
  • Clarification of ASD, Selective Mutism, Social (Pragmatic) Communication Disorder, and other relevant conditions
  • Identification of co-occurring conditions
  • Individualized treatment recommendations
  • Selective Mutism treatment considerations
  • School, college, workplace, or community recommendations
  • Social-communication interventions
  • Recommendations for therapy and supportive services
  • IEP/504 Plan and accommodation recommendations when appropriate

For children and adolescents, results can help families, clinicians, and schools understand not simply whether the child communicates, but what may be interfering with communication, learning, social engagement, independence, and progress.

For adults, the evaluation can provide diagnostic clarification and recommendations related to treatment, college, employment, relationships, social communication, and independent functioning.

The Goal Is Bigger Than a Diagnosis

The goal of a comprehensive ASD evaluation is not simply to answer:

“Does this individual have autism?”

For individuals with Selective Mutism, we also want to understand:

“What is anxiety? What is Selective Mutism? What reflects an underlying social-communication or developmental difference? And how are these factors interacting?”

Understanding these WHYs allows us to develop a much more individualized roadmap for treatment, social-communication intervention, educational support, and everyday functioning.