A mother brings her 5-year-old daughter to the PMHNP for concerns about her speech articulation. She has never sustained a head injury, was not exposed to prenatal toxins, was delivered vaginally without problems, is otherwise healthy, and is developmentally in line with her peers. She has struggled with speech articulation; her daycare teachers first noticed it and she received speech therapy beginning at that time. She has no issues relating with her peers, and she is highly imaginative in her play. Despite having speech therapy, her speech is still difficult to understand. What is the most likely diagnosis?

Choice A reason: Global developmental delay typically involves delays across multiple developmental domains, including motor, social, cognitive, and language skills. In this case, the child is developmentally on track in all areas except for speech articulation, making global developmental delay less likely. Choice B reason: Autism spectrum disorder often presents with deficits in social communication, restricted interests, and repetitive behaviors. This child demonstrates normal social engagement and imaginative play and has no deficits in peer interaction, which makes autism spectrum disorder unlikely. Choice C reason: Speech sound disorder is characterized by persistent difficulties with speech sound production that interfere with intelligibility. The child has received speech therapy but continues to have difficulty being understood. She has normal social and cognitive development, which aligns with a primary speech sound disorder. Choice D reason: Selective mutism involves consistent failure to speak in specific social situations despite speaking in other contexts. This child speaks normally in other contexts, and the concern is with articulation, not selective refusal to speak, ruling out selective mutism.