By Dr. Elisa Shipon Blum 

Imagine walking into a doctor’s office and seeing four patients sitting in the waiting room. Each one has a fever.

The physician walks in, looks around, and says, “You all have fevers. Come into Room 6.”

Without asking questions, taking a history, examining anyone, or determining what is causing the fever, the physician gives all four patients the exact same treatment. Would that make sense?

Of course not.

A fever is a symptom. It tells us that something is going on, but it does not tell us why it is happening. One patient may have strep throat. Another may have the flu. A third may have an ear infection, while another may have pneumonia.

They may share the same outward symptom, but the underlying reasons are very different. And because the “why” is different, the appropriate treatment may also be different.

Selective Mutism Is Similar

When a child, teen, or adult with Selective Mutism is unable to speak or communicate comfortably in certain settings, it is natural for people to focus on what they can see:

“They aren’t talking.”

But focusing only on the lack of speech can cause us to miss something very important. The inability to speak comfortably is part of the presentation. To effectively treat Selective Mutism, however, we need to understand what is making social communication difficult for that particular individual.

In other words, we need to understand the “why.”

The “Why” Is Not the Same for Everyone

Selective Mutism is an anxiety disorder, and social anxiety is commonly associated with it. However, anxiety does not exist in isolation.

Children and teens with Selective Mutism may also have coexisting challenges that affect how they process their environment, interact with others, learn, regulate themselves, and communicate.

For one child, significant social anxiety may be the predominant factor affecting communication. Another child may also experience sensory processing differences that make a busy classroom, noisy lunchroom, crowded activity, or unfamiliar social environment overwhelming. Another may have speech and language challenges that make verbal expression more difficult, increasing anxiety surrounding communication.

Others may have attention or executive functioning challenges, learning differences, autism spectrum disorder, social communication or pragmatic language difficulties, emotional regulation challenges, or other developmental factors that influence communication. And many individuals have more than one factor occurring at the same time.

Two children can therefore have the same diagnosis of Selective Mutism and appear very similar from the outside while having very different underlying profiles. That distinction matters enormously when developing treatment.

Why Focusing Only on Speech Can Limit Progress

If treatment is focused primarily on getting a child to talk, we risk treating the visible symptom without adequately understanding what is contributing to it. It is similar to repeatedly trying to lower a fever without determining what is causing the fever.

A child may learn to answer a question or speak in a particular therapeutic situation, but if we have not addressed the factors interfering with communication, progress may be difficult to generalize to other people, places, and situations. This is one reason we encourage families and professionals to look beyond a simple question such as:

“How do we get this child to talk?”

Instead, we want to ask:

“Why is communication difficult for this individual, with this person, in this setting, at this moment?”

That shift in thinking is critical.

Looking Beyond the Silence

This philosophy is fundamental to the Social Communication Anxiety Treatment® (S-CAT®) approach developed at the SMart Center. We do not view treatment as simply moving a child from silence to speech. We look at the whole individual.

This includes understanding their anxiety profile, comfort level, communication stage, social communication skills, sensory needs, speech and language abilities, attention and executive functioning, developmental profile, learning needs, emotional regulation, motivation, and the environments in which communication is expected.

We also consider an important question: What changes when this individual moves from one person, place, or situation to another?

A child may communicate freely at home but become nonverbal at school. They may speak with peers but not adults. They may communicate with one teacher but not another. They may answer questions but rarely initiate. They may speak in a quiet room but struggle when the environment becomes louder, larger, or filled with more people.

These differences give us important clues. Rather than viewing communication as simply “talking” or “not talking,” we examine where the individual is on the Social Communication Bridge® and what is needed to help them progress.

Assessment Helps Us Understand the “Why”

Understanding the whole child begins with a comprehensive evaluation. This includes learning about the individual across settings, reviewing developmental and medical history, understanding communication patterns, speaking with parents and school professionals, and identifying strengths as well as areas of challenge.

When indicated, additional assessments may be helpful to evaluate areas such as speech and language, attention and executive functioning, learning, sensory processing, autism, social communication and pragmatic language, and emotional or behavioral functioning.

The purpose is not simply to accumulate diagnoses. The purpose is to understand the individual well enough to develop the right treatment plan. The better we understand why communication is difficult, the better we can determine which strategies, accommodations, interventions, and supports are most appropriate.

Why Individualized Treatment Matters

Consider two students who are both silent in the classroom.

The first student may desperately want to participate but experience intense social anxiety and fear of being heard. The second may also have difficulty processing open-ended questions, organizing a verbal response, and knowing what to say socially.

Their outward behavior may look almost identical. Their treatment needs are not.

This is why a single strategy or standardized treatment protocol cannot adequately address every individual with Selective Mutism. Treatment should meet the individual at their current stage of communication and address the factors that are interfering with progression.

The Goal Is Bigger Than Talking

At the SMart Center, our goal is not simply to produce speech. Speech is only one component of communication.

We want children, teens, and adults to develop the ability to communicate comfortably, confidently, and meaningfully across the people, places, and situations that make up their lives. That progression is built through four essential pillars:

Comfort → Connection → Confidence → Communication

As comfort increases, connection becomes easier. As connection develops, confidence can grow. And as confidence increases, communication can expand.

For some individuals, progress may begin with nonverbal communication. For others, it may involve transitional strategies that help bridge from nonverbal to verbal communication. For others, treatment may focus on increasing initiation, elaboration, voice volume, group participation, self-advocacy, or spontaneous social communication.

The path is individualized because the person is individualized.

The Silence Is a Clue

When we see a child who is not speaking, the silence naturally captures our attention. But the silence should prompt curiosity rather than become the sole target of treatment.

  • What is making communication difficult?
  • What happens when the environment changes?
  • What coexisting challenges may be contributing?
  • Where is this individual on the Social Communication Bridge®?
  • What will help them move forward?

When we understand the “why,” we can stop treating Selective Mutism as though every child has the same problem requiring the same solution. Just as a good physician would never treat every fever identically without first investigating its cause, effective Selective Mutism treatment requires us to look beneath what we see.

Because the silence is not the whole story. It is a clue that helps us understand the person behind it.

– Dr. Elisa Shipon-Blum
Creator of Social Communication Anxiety Treatment® (S-CAT®) and the Social Communication Bridge®
SMart Center President & Founder