Selective Mutism

I decided to write a lens on Selective Mutism, as it's a subject close to my heart at the moment. I work within Educational Psychology in the U.K., and work with children who have some form of Emotional and/or Behavioural difficulty. Some of the children need help with friendship or social skills, others have self esteem issues and my favourite area is anger management. I also help children to recognise and appropriately express their feelings and emotions and to be able to identify feelings in others. This is just the tip of the iceberg :)

I am not an Educational Psychologist, I'm an Emotional Wellbeing Development Officer, otherwise known as a EWDO.

I develop programmes of intervention to match the objectives given to me by Educational Psychologists, with whom I work closely. So each programme is developed to meet the individual childs needs. I use a range of available resources, differentiated to suit the childs ability and understanding. If I can't find an appropriate resource, I make it.

My work is completed mostly within mainstream school settings across the City where I live. I usually see children once a week for an hour or so but again this depends on the age of the child & their needs. I have an appropriate member of staff to shadow my sessions so that they can reinforce my work with the child between sessions & it also develops the skills of the staff. Part of my role is to train staff & to provide consultation work.

Some of the children I work with have extrememly complex backgrounds & have already worked with a series of specialist school staff & outside agencies before they reach me.

Many of the children have varying 'labels' of diagnose. This can be ADHD, Autism, Aspergers, Downs Syndrome etc., etc. I love working with Aspergers children as I find them intriguing. I have to confess, I often engage them in discussions about their obsessions & have been found sat on the floor, being taught how to take apart & rebuild BeyBlades...never did get it right!!

That's a very brief intro to my work. I wanted to give a basic understanding of my role & an idea of why I'd be asked to work with a Selective Mute.

I have been trained in a wide variety of areas within Education, Psychology & Special Needs, including Speech & Language. However, I am not a Speech & Language Therapist & my knowledge & expertise in this field is limited.

The reason I have chosen to write a lens on Selective Mutism is that I want to reach people who come into contact with these children. People who are very skilled at what they do, but will be bewildered by these kids. I hope to empower at least one person out there to unlock the world of silence these kids are trapped in.

Below, you will find a case study, the definition of Selective Mutism (according to Wikipedia), a selection of books & some powerful video clips. I hope you find these useful.

Background information
The child in this case study is ten years old. He has never spoken in school. Outside of school he will shout his head off & uses foul & abusive language to one & all.

In school his behaviour, at times, could be disruptive & unco-operative. He did not have any friends & would push others & occasionally trip them up. He never directly hit anyone. Other children tended to 'speak' for him.

The child had, over the years, input from many professionals such as Speech & Language Therapists, Educational Psychologists, Family Doctor etc. He had been included in social communication groups within school & had one on one support with speech & language programmes.

This child is the reason for this lense.

Objectives
1. To build & establish a positive relationship with the child.
2. To see which activities he would engage with & if he would give any verbal interaction.
3. To contribute to hypothesis & forward planning

Classroom Observation
I started my input as I would with any other child, by observing in class. The child gave good eye contact & displayed low level attention seeking behaviours. He approached the class teacher at her desk & just stood & looked at her. No verbal interaction or physical gestures took place. The class teacher had to guess at what he wanted. During my time in class, he threw a pen at another child & used his elbows to create more space for himself at the table. Other children appeared to be wary of him.

The class teacher reported that he was extremely stubborn & often refused to comply with instruction. He would spend playtimes (Recess) alone, wandering around the playground. On occasion, he would push or trip someone over. He made no effort to comminicate in any way. His Literacy skills were judged to be fairly low as he wouldn't read out loud & he wouldn't always complete his work.

The school also reported that he would follow staff members outside the grounds & give a running commentary on their movements. Such as 'Here comes Mr Blake. He's getting his car keys out of his pocket' etc, etc.

With very little experience of Selective Mutism, I approached this case with caution. The first thing I did was to read The Selective Mutism Resource Manual by Maggie Johnson, Alison Wintjens. (from now on, I'll call it the Mutism Manual) This book became my Bible. It gave me an understanding of selective mutism & possible reasons for it. It gave me a set schedule for how to approach the child & ideas for what to do, as well as photocopiable resources with which to do it.

Duration of a session is 45 - 60 minutes & takes place away from the classroom.

Session 1
The week after the observation, I returned & collected the child from class. (I did not have anyone shadowing me as I needed to build a trusting relationship with the child & didn't want to overwhelm him.) The first thing I noticed was his body posture as he stood from his chair & made his way towards me. He hunched over so that his chin was almost buried into his chest & he moved very slowly. We went to a quiet room, without distraction (most important) & I introduced myself & told him the types of things I do with children. I told him it would be fun & a chance for him to relax away from the classroom. As I talked, his body language became more relaxed & he began to gesture & smile. I made it clear that I was not going to try to make him talk, but I would like to help him to talk in school, if that's what he wanted. He indicated that he did by nodding.

This was a very gentle session as I needed to gain his trust.

I gave him a choice of game to play & he choose Go Fish. I told him how surprised I was & how was he going to ask for cards or tell me to Go Fish? Of course, I'd totally under-estimated this childs resourcefulness. He is a skilled artist at what he does & finds ways around talking at the drop of a hat. He showed me the card he needed & pointed to the remaining pack, when it was time for me to Go Fish.

He wouldn't choose a sticker at the end of the session, even though I had given appropriate reasons for giving it to him. He simply couldn't accept it.

During this first session, I had brief eye contact, nodding & shaking of his head, pointing & some stiffled giggles. There were some cautious smiles & lots of cheating!!!

He nodded when I asked if he'd like me to come the following week.

Session 2
When I collected him from class, he again displayed the same body language. It was almost like he was trying to make himself invisible. However, as he got closer to me, there was a glimmer of a smile. As we walked to the room where we worked, he took hold of my briefcase & carried it for me. His posture changed & he took on a stature of someone important. I asked him if he felt like someone important & he grinned. He then thrust the bag back at me & withdrew into himself again. At this point I realised someone else was approaching us.

Once we had settled into the room, I then introduced the Talk Map from the Mutism Manual. We looked at areas where he was happy to talk & to whom & then areas he finds difficult or impossible to talk. This wasn't as easy as it sounds. He didn't want to do the drawing on the map & found it very difficult to indicate where he felt happy to talk. It became very clear that he will happily talk outside of school, even up to the school gates, but never within the school grounds or buildings. I asked if he saw me on the street would he talk to me & he nodded.

During this session, there were more nods & shakes, some grunts, smiles & laughter. Also, foot stamping. At first I thought he was sounding out syllables to words but decided it was just random foot taps. I commented that I thought he was tap dancing. With this, he jumped up & started to dance. This happened on 3 further occasions.

More cheating througout the game, (again he chosse Go fish) & I had to give gentle warnings & give clear expectations of behaviour.

He was beginning to try to control me.

Session 3
This time we completed half of a worksheet from the Mutism Manual called 'All About Me'. I read the questions & he pointed to the relevant answer. This activity highlighted that this child had very low self esteem, would like to speak in school & wanted help to do so. I told him I could help him feel better about himself if he wanted me to... he nodded vigourosly.

I introduced the puppets during this session. He initially seemed pleased & eagerly grabbed one from me. However, he soon had them 'fighting' & as Debbie's puppets don't fight, they went back into my bag before things got out of control, which I feared they might.

I gave him a choice of 3 games & asked him to touch which one he would like to play. I explained that I couldn't always tell which way his eyes were pointing when he tried to indicate which game he wanted ;) However, he was soon cheating & snatching items from me. I told him how that made me feel & that there was no need to cheat.

On the way back to class, we played Follow the Leader across the playground. This soon stopped when other children came into the area & the hunched body posture returned.

Session 4
The child was actually smiling as he came out of class this week. The body posture was the same but I noticed he straightened up a lot quicker today. I showed him the 'American Handshake' I'd been shown on trip to Florida & he happily responded. This was the first pysical interaction we had.

We finished the 'All About Me' activity & this week it also highlighted that he
- would like more friends
- feels shy
- would like to feel differently
- doesn't like the way he is
& thinks others view him as 'silly'.

This week we had the usual nods, shakes, grunts, giggles & he also held his fingers up to show numbers. As his confidence grew, he also showed me the OK sign, & at one point looked as though he was using sign language.

Without warning, he acted as though he was playing music. He did this with rhytmic foot taps, finger clicks & taps on the table. I asked if he enjoys music & he nodded. He was very animated during this spell.

This week, he chose a game that he knew was in a cupboard in the room we were using. He took charge of setting it up, snatched, cheated & dominated how the game was played. I gave very clear warnings that his behaviour was unacceptable & that he needed to follow the rules.

The session ended with the child refusing to leave the room. I gave very clear instructions & consequences & left the room. He soon followed.

Session 5 BREAKTHROUGH!!!!
The room we previously had used was occupied. I was about to return to the main office when the child indicated that he knew of another room we could use. This was a tiny room which contained a small desk, 2 chairs, a keyboard, a tape recorder & some cuddly toys.

The activity this week highlighted that he likes to use his voice loudly outside of school.. I asked him if this was true, to which he replied with 3 very loud grunts.

Without being asked, he turned on the tape recorder that was on the table. He quickly fast forwarded the tape until he found what he wanted to listen to. It was a speech & language session that he'd completed with his teaching assistant. She'd introduced herself on the tape & then introduced the child & he'd made a tiny squeek when asked to say his name, but it was barely audible. Then followed the teaching assistant making animal noises & encouraging the child to do the same. I didn't hear a sound but he was obviously proud & had wanted me to hear. I thanked him for sharing it with me & told him I felt honoured that he'd wanted to do so.

Just after this, he had a nose bleed & I sent him to the restrooms to wash his hands. When he returned, he made some grunting sounds outside of the door & I could hear him giggling. I said in a loud voice 'Is there a mouse outside the door?' he responded with some mousey squeaks. I then proceeded in the same way with cat, dog, horse, elephant & then his name, all of which he replied vocally & said his name. I was on cloud nine!! Of course, when he entered the room, I just said 'that was fun wasn't it' as I knew I shouldn't make a fuss about the fact he had indeed spoken.

He then returned to the tape recorder & pressed play/record & pointed it towards me. I introduced myself on the tape as the teaching assistant had done, & then introduced the child with '& this is ....' & he said his name. It was a very gruff whisper, but he said it. He followed this with an extremely loud cockeral sound (which nearly shattered my ear drums!!). He was beeming with pride & played back the tape time & time again. Then very suddenly, he froze. There was someone in the corridor outside the room & he'd heard them long before I did.

As the session was now drawing to a close, I asked if he'd like to play a game but before I could show him the things I'd brought with me, he was turning on the keyboard. I said Ok, let's play some music. I soon found out that he LOVES loud music. In fact, the louder the better...again, my ear drums suffered :) I asked if he'd like me to find some music books & teach him how to play properly & he nodded. I said 'sorry, I can't hear you because the music is so loud' he replied 'yes' in a gruff voice.

So, things were beginning to move on :) I left the school elated, but very aware that this child has a need to control.

This continues below

Session 6
This week we once again used the small room with the keyboards. A colleague had come up trumps with a very basic 'Learn to play the keyboard' instruction book & I introduced this to the child.

I have no musical skills whatsoever unfortunately & was looking forward to learning alongside the child. However, it soon became apparent that he was just too impatient to learn about middle C etc & just kept playing the pre-set tunes. he gradually increased the volume to an unacceptable level & after asking him 3 times to turn it down, I told him I would end the session early if he did not do as he was asked. He turned the keyboard off.

He came & sat at the table, for which I thanked him & then he jumped back up & turned the keyboard back on louder than ever. I told him his behaviour was unacceptable & that I was ending the session. He totally ignored me until I put my coat on & made towards the door. For a brief moment, he stood in front of the door & blocked my exit. During this time he gave excellent eye contact & I was able to use facial expression in a 'move now' kind of way. He stepped aside & I was able to return him to class. Before he went into the classroom, I told him that I wanted to help him but could only do so if he listened to me & followed instructions.

I was now getting to know the child & felt he could be very intimidating & extremely manipulative at times. He needed to control everything that happened to him & around him. Maybe school was the only place he could do this.

Session 7
I knew I had to regain control & put some structure back into the sessions before things got out of hand & lost effectiveness.

I had decided not to proceed with the activities in The Mutism Manual, as he was not ready for this.

I introduced 'I Am Special' by Linda Schwartz printed by Learning works. This a a booklet of self esteem activites to raise self awareness. Initially, the child was interested in the activities. I only asked for one page to be completed per session. It quickly became apparent that his literacy skills were much more advanced that I had been led to believe by the class teacher. I usually take the pressure off the children I work with & will happily complete any written work for them. All I ask is that they give me the words & I'll write them. I don't want to bring out any anxieties that they may have around producing work. However, in this case, the child was more than happy to complete the activity himself. There was some task avoidance at first such as getting up from the table, looking out of the window, fiddling with the keyboard (which was not only a huge carrot but a massive distraction) but the activity did get finished.

When he was happy with his work & we'd discussed the results (I say 'we' but I did all the talking), the child then turned the tape recorder on again & played back his previous recordings. I asked if he'd like to record anything this week, to which he nodded. He made it clear that I'd have to leave the room first though. He ushered me out & the the other end of the corridor before he was happy to proceed. After a few minutes, he burst out of the room & eagerley gestured for me to return. When he was satisfied that no-one else was in the corridor, he closed the door behind us & pressed play. The recording he made was of animal sounds which progressed in volume, some screeching, keyboard music, & he said his name, albeit in the gruff whisper again.

As a reward, I allowed him 5 minutes free time on the keyboards. I made a point of counting down the time we had left at 1 minute intervals. During this time, he played a selection of tunes to which he became very animated & danced around. He also took my hand & we danced together. He clearly enjoyed this & the interaction between us.

Again I offered a sticker but this time I had with me a fancy sticker chart & said that the stickers could go onto there & I could keep it with me. he happily agreed to this.

The session ended positively & I felt I had regained some control.

Session 9
When I arrived in school, I was called into the Head Teachers office (still scary after all these years!!). She told me about reports about the childs behaviour outside of school. Incidents of verbal abuse were escalatng.

I kept to the same format of the previous session, as this had given me control back & we'd completed work & moved forward.

The child completed the activity from 'I Am Special' & I then asked if he'd like to make a recording for me, to which he eagerly agreed. I asked if this time, he could say his full name & where he lived. He nodded & again, ushered me out of the room & to the end of the corridor.

When he returned, he was obviously excited about the recording & pressed play. On the tape, in a gruff & quiet whisper, he said his name & address. I told him that was great, but I couldn't hear it very well...ears must be getting old...could he possibly do it again using a louder voice? He agreed. So again, the ushering routine took place & I waited... & waited. As the mintues passed, I began to get anxious & wondered what he was up to. Just as I began to make my way back to the room, he opened the door... phew! He had re-recorded what I'd asked & the whisper was much clearer. He'd also answered questions to the next page in the 'I Am Special' activity work book.

This highlighted the fact that he was happy to use his voice if he was not being watched & that he would happily answer questions via a tape recorder.

So, while things were going so well, I asked which game he'd like to play. I'd been asking open questions from day 1 but now I was beginning to put an expectation for an answer into my voice. He nodded towards the Go Fish playing cards. I said that I needed him to tell me what he wanted. Now I knew I was on dodgy ground here, but he could've responded in several ways. However, he chose to tell me he wanted to play Go Fish. It was a quiet, gruff whisper & he contorted his mouth so it looked as though his lips barely moved, but he said it.

When we began playing, I said it would be nice if he could ask for what he wanted this week & to tell me to Go Fish. He shook his head at first but after a couple of turns, the speech began. It was often hard to hear him, but he was talking :) When we finished the game, I told him how much I had enjoyed playing today & it was so much more fun when he fully took part. By wording it that way, it took the emphasis away from the fact that I was pleased he'd spoken, but he was able to understand what I'd meant.

Session 10
When I arrived, the child was sat outside the Head Teachers office as he'd been in trouble for refusing instructions & being unco-operative.

He was particuarly subdued at the start of our session. He indicated that he would like to use the tape recorder & I gave him an activity from 'I Am Special' to complete for me. The usual ushering process took place & when he'd completed the activity he came to collect me from my waiting place in the corridor. He seemed a lot happier by this stage & was keen for me to hear his recording. He'd answered the questions on the worksheet with full sentences, not just yes, no, or one word answers. However, the voice was barely audible. I asked if this was the same voice he used outside of school & he shook his head. I asked if he could record again, usuing his 'outside' voice & he agreed.

The next recording was much better & I was able to fully understand his answers.

I then asked him to tell me which game he'd like to play & again he selected Go Fish. He did this by saying 'Yes' as I held up the pack of cards. I asked him if he could tell me this time when I needed to Go Fish, but he shook his head. However, as we played, I acted as though I was confused & not sure what to do & he soon began to ask for what he wanted & to tell me to 'Go fish'. At the end of the game, even though it was obvious he'd won, I added up my cards & said I must be the winner. He shook his head & giggled. So I asked how many pairs he had. He counted out loud & gave me the answer :)

5 minutes keyboard time given.

As the session drew to a close, he snatched my stickers from my bag. I explained that we do not go into other peoples private posessions & we certainly do not help ourselves to the contents. If he wanted a sticker, then he should ask. He then said 'Can I have a sticker?' & of course I was only too happy to give him one. However, again he refused to take it but wanted to put it in his sticker chart.

Continued below

Below are the final sessions I completed with this child. I have not listed all of them individually but given more of an overview

Session 11 Bad day :(
On this day, the child had been stopped from going on a school trip as he again had been unco-operative & refused to do as he was told.

When we began the session, he continually messed about on the keyboards & I was constantly giving him clear expectations & choices for his behaviour. Then I had to resort to using consequences if he continued. He then sat as though he was ready to begin & as I took his activity book from my bag, he again jumped up & played on the keyboards. I then gave 3 very clear warnings & told him I would end the session if he continued. He chose to ignore me. So I picked up my bag & coat & went to leave the room. At this point, he tried to block my exit & when I told him to move away, he grabbed at my arm. He quickly let go & I left the room.

Obviously, I couldn't leave him there without the staff being aware so I went to the Assistant Head Teacher. He marched down to the room, got the child & verbally wiped the floor with him in the middle of the corridor. The child was visible upset & began to cry. I felt this was totally over the top but I was not in a position to challenge this member of staff & it would've been inappropriate to do so. However, despite being upset, humiliated & scared (his anxiety levels must've been on overload), the child apologised verbally.

He was then sent to sit outside the office & I left the school feeling really bad. I made sure I emailed him at the school to say how sad I was that he'd misbehaved & hoped he was Ok. I also said that I was looking forward to seeing him the next week.

Review Meeting
A review meeting is held for every piece of work I do. I then produce a report from this meeting. We discuss involvement & progress & agree forward actions.

It was agreed that it was time to Slide in another adult to the sessions. I had doubts that the child would accept this but it needed to be handed back to the school & this was the only way to achieve that.

So that's what we did.

Session 12
We took this session back to the room we had used at the start of intervention as there was no keyboard to distract the child ;)

I told the child that in future we would be joined by Mrs Cross & was this Ok? He agreed (much to my surprise). I explained that she wanted to see the things that I do & was not there to watch him.

The child had seen that I had 2 mobile (cell) phones with me. One was personal, the other for work. He indictaed that he would like to talk to me on them. So, I set them up & of course, he ushered me well away from the room before he would proceed with the conversation. I use the term 'conversation' but in reality, it was me asking questions & getting bizarre sounds & some words in reply. But he was talking & using vocal interaction. After about 5 minutes, I told him I was coming back to the room & he told me no, that he wanted to continue. It was time for the session to end & he became agitated & his tone changed to one of aggression.

I returned to the room where he then refused to give me the phone back. I gave 3 warnings & a clear consequence before he returned it to me.

Session 12 Sliding in
The Mutism Resource Manual suggests you slide in another adult gently, so that the child becomes accustomed to them being there & relaxes. I was unsure how this was going to go.

The session went the same way as the previous one & Mrs Cross arrived whilst the child & I were on the phones. I told him that she was with me & he told me to put her on the phone. We looked at each other in amazement as he began to talk to her.

When we returned to the room, he was more than happy to include her in our game & did talk when asked an open question.

Sessions 13-17

These sessions continued much as above really. However, I began to put more & more expectation for verbal responses onto the child. For example, his behaviour was still controlling & manipulative & I started to challenge him. There was a very comfortable chair in the room we used & he would push the plastic one aside & move the comfy one in it's place. So, I told him that if he wanted a different chair, then he should ask & not just assume it was ok. He replied with 'I want this chair' I pushed harder with 'Very good, but it would sound much nicer if you said please & asked rather than tell me what you want' He then responded with 'Debbie, please can I have this chair?' Now I knew I could get a verbal response when he wanted something.

I gradually encouraged Mrs Cross to do the same & he responded in the same way to her.

The school will now continue the sessions into the next academic year & his progress will continue to be monitored.

Now, my involvement is drawing to an end. I only have one more session to complete with this child.

Other issues have surfaced which would be inappropriate for me to write about on a public forum. However, intervention from a higher source has now begun & I pray that the right help & support will now finally reach this child.

It is an appropriate time for me to withdraw, so that others can begin their work.

Whilst at times I have felt sheer exhaustion & frustration that I didn't think I was getting anywhere with this child, he has begun to speak freely in school.

It's a small beginning. Children are reporting to staff that he has spoken to them. It may only be an odd word here & there & it's not always the nicest words, but he is beginning to speak. I have to find the positive in all this & I feel that this has to be celebrated as a massive step forward for this child. He has now completed 6 years in mainstream school & 2 years prior to that in pre-school, without ever muttering a word.

Finally, he is beginning to unlock the silence.

UPDATE!!!

I have now completed my final session with this child. I am so pleased with how things went, I thought I'd share it with you all.

During the last session, he was able to ask for the nice comfy chair again, he laughed out loud several times & he asked for the game of his choosing...albeit in a gruff whisper, but he asked. The game was called BUGS & is a version of dominoes. You have to count the dots on each turn to accumilate your score. I would point to the dots, start coutning & then skip one & wait for him to say the missing number, which he did. I gradually built this up throughout the game & on his last turn, he counted from 1-19!!!

I am so pleased that he has gained the courage to do this. This may seem like a minor acheivement to many but for this child, a 10 year old child who has never spoken in school, he's come a long, long, way & hopefully he'll continue to do so.

Until I began working with this child, I'd only ever come across 2 other children who could possibly be described as Selective Mutes.

The first I did a brief paper on as part of a childcare qualification I was studying for at the time. I got to know her over a couple of weeks & she talked to me via the use of puppets. I started a story & then stopped the dialogue, she took over. When she stopped, I continued & so on. Hers, thankfully, was a very brief period of mutism & within 6 months or so, she would chatter happily.

The second child I came across was described as selective mute but I prefer to think of that time of his life as a crisis episode. The boy had witnessed a tragic road accident in which his best friend was killed in front of his eyes. The psychological trauma resulted in him 'shutting down' for three whole weeks after the incident. During this time, he didn't utter a word to anyone, not even his parents. Within a month, his speech returned to normal, but his behaviour was angry, aggressive & violent. One tragic event has changed this childs life & how he will live in the future.

My personal view is that there must be a reason for a child to stop talking or to choose which areas of their lives that they select to become silent. When I say 'select' I don't mean in the sense of actually thinking about it & deciding not to talk. It's not a conscious decision.

I can recall as a child in class aged around 7 years old, waiting for my turn to read aloud. We'd all have the same book & the teacher would begin the reading & then call a name of a child to take over. I remember the feelings of anxiety, the pounding of my heart, feeling hot & sweaty & just knowing how red my face would go when my turn came. The anticipation & fear of making a mistake & suffering humiliation was almost overwhelming. I can only imagine that maybe the selective mute child also experiences some of these physiological
changes as an expectation to talk is put upon them.

What I have learnt is that when working with these children, as with any other, you need to build a good, trusting realtionship before you try to move on to anything else. Use resources such as the Mutism manual. Read up on the subject to give yourself some background knowledge. Then, go with your gut feeling. If it feels right, do it. If it doesn't, then don't. Use any resources you can find. Don't worry if you don't have a game or activity especially made for Selective Mutes. Ordinary games can have just as much impact. Oh, now there's a gap in the market ;)

Shortly after I began working with the child in the case study, I began reading Ghost Girl by Torey Hayden. I had no idea that the book was about Torey's work with a Selective Mute or that she was a psychologist with a specialism in this field. In the book, she talks about the way she puts an expectation upon the child to answer a question. When I tried it, although it went against everything I'd read, it worked. That's when I began to make progress with the child.

It's not for me to try & decide why this child had stopped talking at school. That was not my objective. It was my objective to see if he would interact verbally & at what level. He has done this & I've met my objectives.

In general, a child may stop talking due to any number of reasons. The anxiety must be so powerful, they simple shut down vocally in certain situations.

Description

In the Diagnostic and Statistical Manual of Mental Disorders, selective mutism is described as a rare psychological disorder in children. Children (and adults) with the disorder are fully capable of speech and understanding language, but can fail to speak in certain social situations when it is expected of them. It ranges in presentation from a reluctance to speak in certain situations to physical and social 'frozen' unresponsiveness. They function normally in other areas of behaviour and learning, though appear severely withdrawn and some are unable to participate in group activities due to their extreme anxiety. It is like an extreme form of shyness, but the intensity and duration distinguish it. As an example, a child may be completely silent at school, for years at a time, but speak quite freely or even excessively at home.

Particularly in young children, selective mutism can sometimes be confused with an autism spectrum disorder, especially if the child acts particularly withdrawn around his or her diagnostician. Unfortunately, this can lead to incorrect treatment. The main difference between selective mutism and autism is that the selectively mute child can communicate normally when in a situation with which they feel comfortable.

Selective mutism is usually characterised by the following:

Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.
The disturbance interferes with educational or occupational achievement or with social communication.
The duration of the disturbance is at least 1 month (not limited to the first month of school).
The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
The disturbance is not better accounted for by a communication disorder (e.g., stuttering) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder.
The former name elective mutism indicates a widespread misconception even among psychologists that selective mute people choose to be silent in certain situations, while the truth is that they are forced by their extreme anxiety to remain silent; despite their will to speak, they just cannot make any voice. To reflect the involuntary nature of this disorder, its name was changed to selective mutism in 1994. However, misconceptions still prevail; for instance, the ABC News erroneously attributed the cause of selective mutism to trauma and described it as willful in a report dated May 26, 2005.[1]

The incidence of selective mutism is not certain. Due to the poor understanding of the general public on this condition, many cases are undiagnosed. Based on the number of reported cases, the figure is commonly estimated to be 1 in 1000. However, in a 2002 study in The Journal of the American Academy of Child and Adolescent Psychiatry, the figure has increased to 7 in 1000.

Typical sufferers have some of the following traits, some of which are often perceived as rudeness [2]:

A difficulty in maintaining eye contact
A reluctance to smile and a tendency to have a blank facial expressions
Stiff, awkward body movements
Particular anxiety in situations where speech is normally expected (answering school registers, saying hello, goodbye, thank you, etc.)
A tendency to worry about things more than other people, sometimes Generalized Anxiety Disorder
A sensitivity to noise and crowds or crowded situations
Difficulty with verbal and non-verbal expression
Frequent temper tantrums at home
Fear of using public restrooms
Compulsive traits, even Obsessive-Compulsive Disorder
Clinging behavior

Causes
Most children with selective mutism have an inherited predisposition to anxiety. They often have inhibited temperaments, which is hypothesized to be the result of over-excitability of the area of the brain called the amygdala[3]. This area receives indications of possible threats and sets off the fight-or-flight response.

Some children with selective mutism may have Sensory Integration Dysfunction (SID), which causes the child to have trouble processing some sensory information. This would cause anxiety, which may cause the child to "shut down" and not be able to speak.

About twenty to thirty percent of children with selective mutism have speech or language disorders that add stress to situations in which the child is expected to speak. Similarly, some children come from bilingual families, have lived in a foreign country, or have been exposed to a foreign language during young childhood and are insecure with the language they are expected to speak. In both these situations, the children have inhibited temperaments, but the stress caused by their language difficulties cause them to become anxious enough about speaking to become mute.

There is no evidence at all that children with selective mutism have suffered abuse, neglect, or trauma but these cannot be ruled out. Children with selective mutism nearly always speak in some situations (though their mutism may progress to the point where they cannot speak anywhere) while children with trauma-induced mutism usually suddenly become silent in all situations.

Treatment
Contrary to popular belief, people suffering from selective mutism do not necessarily improve with age[4], or just "grow out of it." Consequently, treatment at an early age is important. If not addressed, selective mutism tends to be self-reinforcing: those around such a person may eventually expect him or her not to speak. They then stop attempting to initiate verbal contact with the sufferer, making the prospect of talking seem even more difficult. Sometimes in this situation, a change of environment (such as changing schools) may make a difference. In some cases, with psychological help, the sufferer's condition may improve. Treatment in teenage years may, though not necessarily, become more difficult because the sufferer has become accustomed to being mute.

Forceful attempts to make the child talk are not productive, usually resulting in higher anxiety levels, which reinforces the condition. The behavior is often viewed externally as willful, or controlling, as the child usually shuts down all vocal communication and body language in such situations - this can often be wrongly perceived as rudeness.

The exact treatment depends a lot on the subject, their age and other factors. Typically, stimulus fading is used with younger children, because older children and teenagers can recognize the situation as an attempt to make them speak.[5]

Some in the psychiatric community believe that anxiety medication may be effective in extremely low dosages but that higher doses may just make the problem worse. Others in the field believe that the side-effects of psychiatric medications - in any dose and on any child - are so dangerous as to negate any temporary benefit, preferring purely behavioral and psychological interventions.

Effective treatment is necessary for a child to develop properly. Without treatment, Selective Mutism can contribute to chronic depression and other social and emotional problems.[6][7]

Stimulus fading
In this technique the patient is brought into a controlled environment with someone who they are at ease with and can communicate. Gradually another person is introduced into the situation involving a number of small steps.

These steps are often done in separate stages in which case it is called the sliding-in technique, where a new person is slid into the talking group. This can take a relatively long time for the first one or two faded in people.

Desensitization
The subject is allowed to communicate via non-direct means to prepare them mentally for the next step. This might include email, instant messaging, or online chat, until they are in a position to try more direct communication.

Drug treatments
Many practitioners believe that there is evidence indicating that antidepressants such as fluoxetine (Prozac) may be helpful in treating children with selective mutism and even that medicine is essential to effective treatment. The medication is used to decrease anxiety levels to speed the process of therapy. Use of medication would end after nine to twelve months, once the child has learned skills to cope with anxiety and has become more comfortable in social situations[8]. Medication is more often used for older children and teenagers whose anxiety has led to depression and other problems.

However, other practitioners and activists (see articles on Peter Breggin and David Healy (psychiatrist)) stringently decry any use of psychiatric medications on children and note the lack of medical proof of genetic links to behavioral disorders. The denunciation of psychotropic intervention on children with behavioral anxiety disorders has intensified particularly since lawsuits against several drug companies - current to 2005 - have exposed previously unseen internal research documents[9] linking fluoxetine and other SSRI antidepressants with increased risk of suicide, psychosis and - ironically enough - damage to areas of the brain which could affect language production and normal social development.

Medication, when used, should never be considered the entire treatment for a child with selective mutism. The child should, while on medication, be in therapy to help him or her to know how to handle anxiety and prepare him or her for the world[10].

References
1. ABC News: Traumatized Girl Wills Herself to Silence

2. Selective Mutism Group FAQs: Are there other associated behaviors or personality traits?

3. SMart Center: What is Selective Mutism? http://www.selectivemutismcenter.org/WhatisSM.htm

4. Johnson M & Wintgens A (2001) The Selective Mutism Manual. Bicester: Speec

5. ABC News: Traumatized Girl Wills Herself to Silence

6. Selective Mutism Group FAQs: Are there other associated behaviors or personality traits?

7. SMart Center: What is Selective Mutism? http://www.selectivemutismcenter.org/WhatisSM.htm

8. Johnson M & Wintgens A (2001) The Selective Mutism Manual. Bicester: Speechmark

9. Ricki Blau "The Older Child or Teen with Selective Mutism"

10. Selective Mutism Group: Ask the Doc archives http://www.selectivemutism.org/faq/faqs/when-do-i-need-to-seek-professional-help-for-my-child

Cultural references

(1948) The Makioka Sisters, a novel by Junichiro Tanizaki, is published in Japan, its characters modeled upon real members of the author's third wife's family. The distinctively 'shy' character of Yukiko, who challenges her family with a stubborn refusal to marry, is based on a sister who may have had selective mutism.

(2000) The title character of Dori Jones Yang's novel The Secret Voice of Gina Zhang has selective mutism complicated by bilingual issues. When she begins school in America, she finds that her throat closes up when she attempts to speak in English or her native language, Mandarin.

(c. 2001) In the Disney Channel original series Lizzie McGuire the character Lenny Onassis, a friend of Matt McGuire, is selectively mute and only communicates to Matt.

(2001) The song "She's Given Up Talking" by Paul McCartney (from the album Driving Rain) conforms almost perfectly to a clinical description of selective mutism in childhood, describing a young girl who is mute at school yet normally talkative at home ("When she comes home it's a yap yap yap/ words start to flow like water from a tap").

(2008) Rajesh Koothrappali in the series The Big Bang Theory is unable to speak around women, but this is suppressed at different points by alcohol and an experimental anti-anxiety drug.

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