Child and adolescent mental health

Selective mutism

What is selective mutism?

Selective mutism is a severe anxiety disorder where a child or young person is unable to speak in certain social situations, such as at school or even home when relatives they do not see very often are visiting. If left untreated, can persist into adulthood; with early intervention the prognosis for recovery is good It is important to understand the child does not refuse or choose not to speak at certain times, they are literally unable to speak; the expectation to talk to certain people triggers a freeze response with feelings of panic, and talking is impossible. However, they are able to speak freely to certain people, such as close family and friends, when nobody else is around to trigger the freeze response. 

Symptoms of selective mutism

Selective mutism usually starts in early childhood, between age 2 and 4. It's often first noticed when the child starts to interact with people outside their family, such as when they begin nursery or school.

The main warning sign is the marked contrast in the child's ability to engage with different people, characterised by a sudden stillness and frozen facial expression when they're expected to talk to someone who's outside their comfort zone.

They may avoid eye contact and appear:

  • nervous, uneasy or socially awkward

  • rude, disinterested or sulky

  • clingy

  • shy and withdrawn

  • stiff, tense or poorly co-ordinated 

  • stubborn or aggressive, having temper tantrums when they get home from school, or getting angry when questioned by parents 

More confident children with selective mutism can use gestures to communicate – for example, they may nod for "yes" or shake their head for "no".

For a diagnosis to be made, the condition must:

  • the child does not speak in specific situations, such as during school lessons or when they can be overheard in public

  • they can speak normally in situations where they feel comfortable, such as when they're alone with parents at home, or in their empty classroom or bedroom

  • interfere with the child’s education and social and cognitive development

  • the duration of selective mutism has lasted at least one month or two months in a new setting such as school or nursery

  • the failure to speak must not be due to a lack of knowledge of the language

  • the condition cannot be better explained by behavioural, mental or communication disorder. There is no relationship between selective mutism and autism, although a child may have both.

 

Selective mutism appears to be more prevalent amongst girls and children from migrant and multi-lingual families, although the reasons for this are currently unknown.

Case studies

Christina Kim-Symes is 23 and was diagnosed with selective mutism 20 years ago. When she was three, her mum worked on techniques with her at home to encourage her to speak, with support from professionals. Although there was underlying anxiety that remained constant throughout her early school life, this professional intervention was generally successful. However, as adolescence approached, the new social pressures were overpowering and she mainly only spoke to people online. School attendance became increasingly sporadic as, when there, she was hardly able to communicate with peers and teachers and most lunch and break times were spent in the toilets in tears. She developed severe depression and spent time in a psychiatric hospital. After she was discharged, she started at a different school which supported her with reasonable adjustments and she was able to take her GCSEs. She has since successfully completed art college and, although she still has times when she is entirely overwhelmed with anxiety and selective mutism rears its head, she is proving to herself, and to others, that it is still possible to achieve things and live a life, despite the challenges she faces.

Matt Holdback developed selective mutism around the age of five. He remembers being a confident chatty child but when he was at school he went quiet, stopping talking to teachers, friends, dinner ladies, basically anybody. He remembers sitting in the classroom with the teacher doing the register, shaking and sweating at the possibility of being made to answer in some format. This anxiety soon transferred from the classroom and into the playground, escalating as time went on and through the transition from infant to junior school. Deep down and in his head he was desperate to talk, wanting to be a normal boy with close friends. Matt potentially puts his selective mutism down to it starting around the same time my parents split up and went in separate directions.  Matt was a completely different child at home to what he was at school, in his Mums words “They [his siblings] just couldn’t shut you up!”. Football was the biggest and best tool that brought him out of his shell; he went from using body language and gesturing to making the occasional noise, and soon progressed into words and  his confidence grew. It was a gradual progression from around the age of 8 or 9, but he started making conversation with people and became able to open up at school as he would at home. Matt now runs kids' activity and sports camps, enabling children to develop their own personalities and grow as individuals. In 2012 he was selected to run with the Olympic torch in Gloucestershire because of his past experiences and for what he does now.

Lindsay Whittington, Co-ordinator and founding member of SMIRA (Selective Mutism Information & Research Association) tells the story of her daughter's selective mutism from the age of 18 months, when she became very shy and clingy. By age 3, on starting at playgroup, it was obvious that she was more than just shy. Upon starting school, although she knew the teacher, knew the premises and knew a lot of her classmates, she remained silent, her body language often stiff or ‘frozen.’ A psychiatrist told her parents she had elective mutism (the name was later changed to selective mutism and it was to be hoped that she would grow out of it. He did not know what would happen if she didn't. Fortunately, Lindsay was later put in touch with Alice Sluckin, a retired psychiatric social worker with a special interest in selective mutism, who befriended the family and gave advice to the schools her daughter attended. On changing primary school after a move and the birth of a new sibling, the little girl began to talk at school. Although she remained very quiet, and had a lot of catching up to do, it was a breakthrough. She is now a mother herself, and has become a very chatty young lady!

Websites and web pages

Anxiety Canada™ is a leader in developing free online, self-help, and evidence-based resources on anxiety and anxiety disorders and promotes understanding about anxiety and anxiety disorders  in children, young people and adults. They have a page dedicated to GAD in children and adolescents, including an animated video about symptoms and strategies.

The Child Mind Institute is an American, independent, national non-profit organisation dedicated to transforming the lives of children and families struggling with mental health and learning disorders. They explain what to look for if a child might have GAD; risk factors; diagnosis; and treatment.

The University of Rochester Medical Center (URMC) is one of America’s leading academic medical centers. It forms the centerpiece of the University of Rochester’s health research, teaching and patient care missions. Although some of the information given here may not be applicable to the UK, it gives a comprehensive overview of what GAD is and how it presents in children and teens; possible causes; diagnosis; ttreatment; and how parents can help their children.

Canadian mental health website for teens and young people creating, developing and deliveing  nationally and internationally recognized research, education and clinical programs by collaborating with health care providers, policymakers, schools, the business community, non-profit organizations and the general public. They explain what GAD is and how it differs from normal anxiety; causes and risk factors; how to help someone with GAD; and treatment available.

Diagnostic criteria

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