The Ultimate Guide to SLCN

Selective Mutism

Selective Mutism (SM) is a specific anxiety-related disorder commencing in early childhood where there is a persistent failure to speak in specific situations, despite being able to speak freely in another more familiar situation. These children typically have well-developed language skills and are unaware of why they cannot talk. SM is a phobia – the child wants to talk (as we all do) but an overwhelming anxiety means that they are unable to do so. Just the thought of being put in a situation where there is an expectation of talking can cause a child with SM to freeze with panic. These children are at a significant disadvantage in terms of their personal, social and academic development and it’s very important to remember that they are not being naughty – SM is not a choice.

Myth Busting

Do children with Selective Mutism choose not to talk in some situations?

Selective Mutism is not a choice. It is a phobia that a child cannot overcome without considerable support.

SaLTs and other professionals working with SM usually differentiate between the terms “reluctant talker” and “Selective Mutism”. Reluctance to talk is not a milder form of SM or a ‘softer’ name for SM. We are all reluctant to talk at times for a number of reasons. A reluctant talker is anxious about speaking and may have low confidence in speaking. These children are at risk of developing SM if they do not receive timely and appropriate support.

SM typically develops between the ages of 2-5 but it is usually recognised when children are a little older, often when they start nursery or school, as this is when children begin interacting with more people outside of their immediate family. It is diagnosed when the child has been unable to speak in specific situations for at least one month, or two months in a new setting (e.g. when they start school or nursery), the failure to speak is not related to lack of knowledge of the language or better explained by another communication disorder, and the difficulties have a significant impact on the child’s academic and social functioning. It can be especially difficult to diagnose in children with EAL, since it is common for children to experience a ‘silent period’ when they are first exposed to an additional language. This usually lasts for approximately one month, although it’s sometimes longer. To complicate things further, the prevalence of SM is thought to be as much as three times higher in multilingual and migrant populations. If a child with EAL has a ‘silent period’ of more than one month, it would be appropriate to make a referral to SaLT.

Top Tip

Build rapport with the child on a one-to-one basis using activities and games which don’t require the child to talk.

There is a known link between SM and anxiety. It is thought that children with SM are genetically and temperamentally predisposed to general feelings of anxiety, and they may become specifically anxious about talking following a triggering event such as becoming separated from their parents or carers or feeling overwhelmed in a busy environment. In most cases it is not possible to identify an exact cause, but it’s important to remember and to reassure parents that it’s nobody’s fault.

Children with SM are at higher risk for going on to develop anxiety disorders later in life. There is also a significant risk of educational underachievement, as children with SM are less able to participate in their education. They may be unable to ask questions to clarify their understanding and often have a general fear of making mistakes which can limit their progress. They may also be at higher risk of toileting accidents or urinary tract infections as they are unable to ask to be excused or may avoid doing so – some children and young people will go so far as to limit their food and drink intake at school so that they won’t need to go to the toilet.

SM can be diagnosed by a SaLT or a psychologist, however diagnosis from a professional is not always necessary in order to support the child effectively. The strategies and interventions for supporting a child with SM will not be detrimental to any child. It is more important to understand when a child is at risk of developing SM and for school and parents to work together to start resolving the child’s difficulties as soon as possible.

Children who are identified early and receive appropriate support can be expected to make a good recovery, but the longer a child goes without receiving intervention the more entrenched the condition becomes and, ultimately, the more difficult it is to treat. Left untreated it can persist throughout childhood and adolescence and even into adulthood.

Prevalence

The prevalence of SM for primary-school aged children is reported to be 0.7-2%, however, this is regarded as an underestimation of the true scale, as the condition is generally not well recognised or understood. About twice as many girls as boys are diagnosed and it’s more common in multilingual and migrant populations.

What to look for

Children with SM will be able to talk freely in some situations (e.g. at home), but will not speak in other situations. The pattern of talking will vary between children – in more extreme cases the child might only be able to talk to one of their parents at home, while in another case a child might be able to talk in most environments to some people, but not to others. They may be able to give single word or heavily rehearsed responses, but unable to engage in conversation or answer open questions.

When faced with a situation where there might be an expectation to talk, children with SM may appear ‘frozen’ or have a blank facial expression. Often, children will learn to avoid situations which they anticipate will require talking, and they can become afraid of particular people who might try to encourage them to talk. Children with SM will often find it difficult to participate in routine activities at school, such as answering their name in the register, and they may be unable to express their basic needs or preferences, such as asking to go to the toilet or choosing what they would like for lunch. These children are highly vulnerable to social isolation.

Difficulties

• Inability to talk to certain people
• Inability to talk in certain situations
• May be socially isolated
• Struggle to join in with certain activities
• Difficulty expressing needs and preferences
• May be fearful or avoidant of particular situations and people, or of new places and people where the expectations are unknown
• Children with SM might avoid eye contact or find it difficult to look at you when they’re feeling anxious, because making eye contact can encourage people to talk to you
• Children might appear rude because they can’t respond, and they can’t say please or thank you – but this is unintentional
• Children with SM often find it difficult to express their emotions. When they are at school they may be feeling highly anxious all the time, so this can make it hard to smile or laugh and they might appear to be expressionless. Being unable to express their feelings can cause even more anxiety.
• A child with SM might move more stiffly or awkwardly than other children
• Children with SM are often sensitive and they worry more than other children. Some children with SM have traits of perfectionism.

Myth Busting

Is SM an indication that a child has a history of trauma or abuse?

Several studies have found no evidence that links SM to a history of abuse, neglect or trauma and, while it is often thought that SM stems from a negative experience around being required to speak, it’s usually impossible to identify any triggering event. There is another condition called Traumatic Mutism – when a person is suddenly unable to speak in any situation following a traumatic experience – but this is a separate disorder with different characteristics.

Is SM just shyness – something that the child will grow out of?

Children who are just shy will warm up to a new situation given a little time and would almost certainly be able to express their basic needs if it were really necessary. This is in contrast to a child with SM who is unable to speak even when they really need to and even in familiar and comfortable situations. It is not normal for a child to remain completely silent indefinitely.

Can I persuade children with SM to talk if I offer them a reward?

Pressure to speak is exactly the thing that children with SM are anxious about, so adding more pressure to try to coax them into conversation is not an appropriate strategy. Attempts at bribery will only lead to increasing anxiety and this will reinforce the SM. Interventions instead need to focus on reducing anxiety and removing expectations to talk so that the child is able to relax and feel comfortable.

Are children with SM just being stubborn and defiant?

Selective Mutism was previously known as ‘Elective Mutism’, which gave the impression that this response is something that the child is choosing. This name has since been abandoned, and SM is now recognised as a phobia relating to anxiety around the act of speaking rather than coming from a desire for control. Young people who have recovered are very clear that they experienced being unable to speak rather than choosing not to speak. Behaviour which appears to be oppositional or defiant, such as refusing to attend an event or participate in something, might actually be an attempt to avoid a highly distressing situation.

Strategies

• It is essential to remove all pressure on the child to talk. Make sure that no-one applies pressure to talk using rewards, persuasion or negative comments.
• You will need to reassure the child that you will not call on them or single them out to respond to questions, read to the group or demonstrate something unless the child volunteers or lets you know that they would like to be chosen.
• Set up a home-school communication book for two-way communication through parents. Let the child know that if they have anything they want to share with you, e.g. if they feel upset about something or have exciting news, then they can use this journal to let you know.
• Tell the child privately that you know they want to talk but are finding it difficult and reassure them that they will talk when they are ready and feel less anxious. Reassure him/her that until then they can join in with activities in whatever way they feel comfortable.
• Reassure them that they can join in by listening, pointing, nodding, etc. Ensure that you create opportunities to involve the child in activities which do not require them to speak –creative projects, arts and crafts and physical activity can be particularly successful.
• Try using activities in the classroom in which the children act, move, talk, or sing in unison and make it clear that nobody will be singled out during these activities.
• Talk about what you are doing using a running-commentary style of speech and pause so children can join in when they feel ready: ‘Wow, look how tall you made your tower!’; ‘This is fun, isn’t it?’; ‘I wonder where this goes….’, but don’t expect the child to respond. Try to make comments rather than asking direct questions, and if you do ask a direct question by accident you could answer it yourself.
• You can ask rhetorical or indirect ‘wondering’ questions, e.g. ‘I wonder where this came from?’ or ‘Isn’t that a pretty flower?’, as these give the child an opportunity to respond if they want to, but don’t actually require a response.
• Ensure that children can access the toilet, drinking water and first aid without asking verbally.
• Offer the child choices and encourage them to use gesture or pointing to make their preferences known.
• Consider alternative ways to carry out your class registration. For example, you could ask
  ‘Is _______ here?’ so that the whole class can answer together, or you could ask children to knock on the table or clap to show that they are present.
• Actively support the development of friendships and inclusion in pastoral activities. Show by your own example how to involve quiet children and have fun.
• Do not draw attention when the child speaks; respond as if they have always spoken. Play an active role in managing the responses of other children.
• Give a friendly and positive response when the child makes any communication. If they use gesture or whisper to communicate with you, respond as naturally as possible with your normal speaking voice.

Role of SaLT

A SaLT can offer advice on management of SM, however direct intervention from a SaLT is usually not recommended as it is more appropriate for support to be delivered by key people who are already known to the child. It is strongly recommended that if you suspect a child you work with may have SM or has an existing diagnosis that you seek further training and advice. Depending on the services available in your local area, you may find that you can access support, training or advice from your local SaLT team, Educational Psychologists, CAMHS, or Specialist Teachers. Keep in mind that a child with SM can have additional SLCN, although these can be difficult to assess. The Language Link assessment can be useful to identify if the child has any difficulties with their understanding of language, although the assessment would need to be carried out with some care, for example reassuring the child that they will not have to do any talking and ensuring that the child knows what to do if they don’t know the answer or aren’t sure. The same considerations would apply to any interventions carried out with the child so that they don’t feel anxious about talking.

Further Information

The Selective Mutism Resource Manual: 2nd Edition, by Maggie Johnson and Alison Wintgens

Smira – www.selectivemutism.org.uk

Read more about Selective Mutism in The Link magazine, issues 6 & 1