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Can my child have both autism and selective mutism, and be treated for both?

The two can't be diagnosed together, though some of the treatment is similar 

Steven G. Dickstein, MD

Pediatric Psychopharmacologist, formerly with the ADHD and Disruptive Behavior Disorders Center
Child Mind Institute

Q: My 8 year old son has just been diagnosed as having mild autism spectrum disorder. From the age of 3 until about 6 years he has displayed all the characteristics of selective mutism.  He talks quite a bit at home but was completely silent at preschool. We have been treating him for SM, and he has improved to the point where he can now answer the teacher's questions, and can talk quietly to one of his friends in class. In the last 12 months we have noticed some other unusual behavior, and our psychologist now says he is on the autism spectrum, which means he can't have SM too. Is that correct, even though we are being told to continue treating him for SM?

A: Your psychologist is right that it's not technically possible under current DSM-V criteria to be diagnosed with both selective mutism and autism. But we know diagnoses aren't perfect, and it isn't unusual for diagnoses to change as children develop.

At one developmental stage a child may not look that different from his peers. At age 3, subtle differences in communication are not that easy to pick out, especially in high-functioning kids. It's only when children are older, and start to miss developmental milestones for social behavior, social appropriateness, social connectedness, that they start to more clearly look different from their peers.

Kids with SM are different from those with autism; in comfortable situations, SM kids interact just fine, with a full range of emotion, and awareness of social interpretation. It's only when they become uncomfortable that they fall silent.

Kids on the autism spectrum have a qualitative difference in how they understand and interact socially. They have a hard time interpreting subtleties of social interaction, whether or not they're in comfortable or uncomfortable settings.

Interestingly though, in this case, the treatment that we recommend for selective mutism isn't that different, in approach, from what's recommended for kids on the spectrum, called applied behavior analysis, or ABA. ABA is really about helping kids develop by giving positive rewards for small behaviors, broken down step-by-step. For SM we do exactly the same thing-we help kids find their voices by giving them labeled praise for small behaviors broken down into small steps we call "brave talking." Though, to be clear, we expect that children with those different diagnoses respond differently to treatments, and the goals and expectations are always tailored to the child's specific strengths and challenges.

So while there are a lot of parallels, the difference is in our assumptions of what kids understand or feel socially, and our expectations and goals for them.  A child with autism who's not talking may not be thinking or feeling the same thing as child with SM, who is typically afraid of being judged or being ashamed. As Temple Grandin describes so articulately, autism makes a person think differently, we have to try to understand how a child is viewing the world in order to help him get the tools to do what he needs to do. A child on the autism spectrum may need a more explicit kind of instruction in social interaction, translation of what may be understood by others, a different kind of coaching to get him on the best possible trajectory.

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