Selective mutism

You may know your child as an outgoing chatterbox in one situation who just stops talking in other situations. If you haven’t experienced this, it’s easy to underestimate how profound the change can be. The chatty child on the way to school stops talking as they go through the nursery or school gate and doesn’t utter another word until collection time six hours later. It’s often the move to nursery or school that first raises the problem and it can have a big impact on a child’s social, emotional and intellectual development.

At first glance the condition appears fairly easy to spot, but there remain real questions about how to diagnose selective mutism and how common it is. Some studies have estimated it to be quite rare with about three children in 10,000 affected; while others have suggested it’s as common as seven in every 1,000.

What is fairly consistently recognised is it starts at around three to six years old, but is often missed until school starts. Even then it can be difficult to firmly establish the nature of the problem.

Most children will grow out of it to some extent; however, many will remain reserved when it comes to speaking, and feel quite anxious in some social situations even into their adult years.

Diagnosis and treatment of selective mutism

One of the problems getting a diagnosis and treatment is that symptoms that make up selective mutism can be caused by a number of factors:

• Hearing impairment – in a small number of cases it’s simply that in a louder and more chaotic school environment a hearing problem emerges that is less apparent at home.
• Speech impediment – many children with selective mutism have problems with pronouncing certain words or forming certain sounds.
• Development of thinking skills – children don’t develop in a uniform way, one child’s ability to make sense of a social situation may vary widely from that of another child of the same age.
• Asperger syndrome – this is a mild form of autism that can affect a child’s ability to make social interactions.
• Anxiety – selective mutism can be associated with a number of anxiety-related disorders such as obsessive-compulsive disorder or panic disorder. Social anxiety is often more likely, where the sufferer can become preoccupied with thoughts that other people are thinking negatively about them.
• Adjustment – for some children the transfer from the family to the school environment can trigger feelings of mistrust and fear of people outside of their immediate family.
• Trauma – if a situation is associated in a child’s mind with a traumatic event, they may try to withdraw or avoid it, in an attempt to either prevent a repeat of the trauma or the memory of the trauma.

A child with a hearing impairment whose rather quirky way of expressing certain words can be seen as endearing and accepted within a close knit supportive family, but may get received differently at school, leading them to feel judged and not accepted and so withdrawing.

For this child while the experience may affect them, there is probably no long-term consequence

Alternatively for the child with Asperger’s or some deficit in the development of their ability to make sense of their environment and think things through, selective mutism is a sign of a more serious problem that needs addressing.

Assessments for selective mutism

Given the possible complexity of the problem before any firm diagnosis is made or treatment suggested, there should be a very thorough period of assessment looking at as many possible aspects of the child’s life. However, this can be impractical because such thorough assessments are expensive, time consuming and education authorities can need persuading that it is worth doing given that the child may grow out of the problem. Many assessments will also need the child’s participation, which may be difficult if they’re mute in the presence of the speech therapist or psychologist. This can make the process of assessment seem like a long road, adding to what is already a stressful situation.

Treatment can be as simple as fixing a hearing problem and working through a course of speech therapy. Alternatively, a number of strategies from behavioural therapy might be needed to encourage the child to begin interacting with situations in a different way.

These could include looking at how teachers and peers are inadvertently encouraging the selective mutism by not including the child in activities or by communicating through notes or signs for instance. These issues must be dealt with before anything else can be addressed.

A programme can be designed to help the child, for example giving positive rewards for speaking in less difficult situations, which can be slowly built upon. They may benefit from starting by speaking in front of only one class mate and then increasing the number. Some children may benefit from being filmed and playing the footage back to them may be a very powerful exercise.

Involving the family in this process can be another powerful strategy to support the child through the process of change and help address any problems of adjusting to situations outside of the family unit. In some cases anti-depressant medication can be helpful.