Anxiety and Speech in Children

Anxiety can make a child go quiet in particular places, because a child who feels watched or judged can freeze, even while talking easily at home. When that silence is consistent and lasting in settings where speaking is expected, such as school, it has a name: selective mutism, which is classed as an anxiety disorder.

What you’ll learn

• How anxiety can stop a child talking in some places and not others
• What selective mutism is, and how it differs from settling in or learning a new language
• What helps at home and at school, and what can keep the silence going
• Who evaluates a child’s silence, and when to ask

Can Childhood Anxiety Cause Speech Difficulties?

Anxiety can make speaking hard in particular situations, even for a child who talks easily elsewhere. Some fear and anxiety is part of every childhood, according to the American Academy of Child and Adolescent Psychiatry (AACAP), and an anxiety disorder is considered when a child does not outgrow the ordinary fears and worries of early childhood, or has so many that they interfere with school, home or play.

Talking is one of the places anxiety shows. Social anxiety, as the National Institute of Mental Health (NIMH) describes it, is fear in situations where a person may be watched, evaluated or judged, and it usually starts in childhood or adolescence. Among the ways it can appear in children, NIMH lists not speaking or not joining in social situations. The Centers for Disease Control and Prevention (CDC) adds that some anxious children keep their worries to themselves, so the anxiety can go unnoticed.

The body takes part as well. The American Speech-Language-Hearing Association (ASHA) lists physical signs of anxiety such as a freeze response, a stiff or restricted way of moving, and little or no facial expression or eye contact. ASHA also notes that a child may still communicate without words, through posture, gaze, expression or gesture, in settings where they feel more comfortable.

Anxious silence and a speech delay are different questions, one about where a child talks and the other about how talking develops, though the two can occur together. ASHA notes that children with selective mutism may also have a communication delay or disorder.

Talking at Home, Silent at School: Selective Mutism

When a child consistently does not speak in specific social situations where speaking is expected, such as school, while speaking in other situations, ASHA calls the pattern selective mutism. AACAP lists speaking at home but not at school or with friends among its signs, and ASHA notes that the child is generally able to talk with people, and in places, that are familiar.

Citing the diagnostic manual of the American Psychiatric Association, ASHA classes selective mutism as an anxiety disorder. A 2020 analysis of 22 studies, published in the journal Child Psychiatry and Human Development, found that 80 percent of the children with selective mutism in those studies had also been diagnosed with another anxiety disorder, although the results varied considerably from one study to the next.

Selective mutism is uncommon: the prevalence estimates ASHA cites mostly run from 0.2 to 1.6 percent, and no single cause has been identified. ASHA also lists conditions that can occur alongside it, among them social anxiety, separation anxiety, autism and speech or language disorders, which is one reason speech-language pathologists are often involved.

From clinical practice

Chatty at home and silent at school, a child is easy to read as stubborn, or even rude. The pattern is better read as a freeze, with anxiety holding the child still in one setting. The National Library of Medicine’s MedlinePlus encyclopedia says that, in most cases, a child in this situation truly cannot speak there.

The freeze explains the usual advice. Pressure to speak tends to make it stronger. Time, choices and a way to answer without words take some of the weight off the moment.

How Selective Mutism Differs From Settling In

Settling into a new school and learning a new language can both bring a quiet spell that looks like selective mutism at first. ASHA’s summary of the diagnostic criteria requires the silence to last at least a month, and the first month of school is left out of that count, because children may be shy while they settle in. The silence also has to get in the way of learning or of social communication.

Learning a new language brings its own quiet. ASHA explains that a child meeting a new language may stay quiet for a short silent period, and that talking freely with speakers of the home language is part of ordinary second-language learning. The silence of selective mutism does not come from unfamiliarity with the language, and a multilingual child with selective mutism stays silent in both of their languages.

Shyness is a separate matter again. NIMH notes that social anxiety can look like extreme shyness, and ASHA lists a shy or timid temperament as one possible contributing factor, but shyness is not the same thing as selective mutism. For a child whose quiet comes from temperament, encouraging a shy child to talk sets out what helps.

What Helps When Anxiety Stops a Child Talking

ASHA points to three habits that may strengthen an anxious child’s silence: answering for the child, explaining the silence away, and pushing the child to speak. Each is an understandable response to an awkward moment, and the effect on an anxious child is rarely explained to families. The approaches ASHA describes keep the pressure low instead:

• Allow plenty of time. Waiting through a pause, instead of filling it, leaves room for an answer.
• Offer choices. ASHA suggests giving a child options to choose between, in place of open-ended or yes-or-no questions.
• Accept answers without words. Pointing, showing, gesturing or drawing all count as communicating when the words will not come.

For anxiety in general, the American Academy of Pediatrics suggests helping a child face fears gradually and praising and rewarding brave behavior, since the aim is coping instead of avoiding. For a child who goes silent, a brave step can be small, and small steps are also the basis of professional treatment.

At school, ASHA suggests small cooperative groups that include the classmates the child prefers, starting group work with signals, gestures, pictures or writing, giving the child jobs that need no talking, and watching for small improvements to encourage.

How Selective Mutism Is Evaluated and Treated

ASHA’s position is that a complete differential diagnosis of selective mutism, meaning one that rules out other explanations, comes from an interdisciplinary team with behavioral health professionals on it. Speech-language pathologists often work with school teams and with psychologists, psychiatrists or school social workers, and a speech-language pathologist with advanced training in selective mutism may diagnose it where state credentialing law allows.

The speech-language pathologist’s own part is a full evaluation of speech, language and communication, with hearing checked to rule out hearing loss. For a child who may say little in a clinic, the speech-language pathologist can ask parents to film the child talking at home, then compare that recording with what the child does in the clinic or at school.

Treatment for selective mutism aims to lower anxiety and increase speaking across settings, through practice in small, nonthreatening steps. One approach ASHA names, stimulus fading, starts with the child speaking comfortably and gradually adds a feared element, such as an unfamiliar person in the room.

Treatment can take place in the clinic, at school and in the community, and ASHA describes the involvement of the child, the parents and school staff as integral. The CDC notes that cognitive behavioral therapy is used for anxiety, particularly in older children, and that for very young children, involving parents is key.

When to Ask a Professional About Anxious Silence

NIMH’s guidance is to consider getting help if a child’s emotions or behavior persist for weeks or more, distress the child or the family, or disrupt school, home life or friendships. AACAP advises considering an evaluation by a qualified mental health professional or a child and adolescent psychiatrist when anxiety becomes severe and interferes with usual activities, such as separating from parents, going to school or making friends.

ASHA’s advice to parents is to raise any concern about selective mutism with a doctor, who can refer the child on to a psychologist or psychiatrist for the anxiety, while a speech-language pathologist can look into speech and language. A parent of a child under three can also contact the state early intervention program directly, without a pediatrician’s referral.

A child who loses words or skills they once had, at any age, is showing a different pattern from silence in one setting, and that loss is reason enough on its own to call your pediatrician. Other signs worth a professional look are gathered in when to get help for a speech delay, and the wider picture is in speech and language development.

Common Questions From Parents

What Is Selective Mutism?

Selective mutism is an anxiety disorder in which a child does not speak in certain social situations where talking is expected, such as a classroom, while speaking freely elsewhere, generally with familiar people. It is uncommon, and most of the estimates ASHA cites range from 0.2 to 1.6 percent of children.

My Child Talks at Home but Not at School. Why?

School is a place where a child may feel watched or judged, and anxiety there can bring on a freeze that holds speech back. Any worry can be raised with your pediatrician, and silence that continues past the first weeks of school is worth raising.

Is Selective Mutism the Same as Being Shy?

No. Shyness is largely a matter of temperament, while selective mutism is considered an anxiety disorder. A shy temperament may play a part, but the silence is consistent, tied to particular settings, and, MedlinePlus notes, in most cases not a choice.

Who Diagnoses Selective Mutism?

ASHA describes diagnosis by an interdisciplinary team, including a psychologist, psychiatrist or other behavioral health professional, as the way to rule out other explanations. A speech-language pathologist may also diagnose it, with advanced training and where state law permits. A pediatrician is a sensible first conversation.

Should I Make My Child Say Hello to People?

Insisting can backfire: pressuring a child to speak is one of the habits ASHA says may reinforce silence. A wave or a point can stand in for the word, and praising that small, brave step fits the American Academy of Pediatrics’ advice to face fears gradually.

Can Anxiety Cause a Speech Delay?

Anxiety affects where a child talks, which is a different matter from a delay in learning to talk. The two can occur together, though: ASHA lists speech and language disorders among the conditions that can accompany selective mutism, which is why speech and language are evaluated as well.

Reviewed by Monica d’Errico-Franklin, M.S., CCC-SLP

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