Belle* is six years old. Like many children, she is a playful and often boisterous child at home with her family. Unlike many children, she has an anxiety disorder which renders her speechless and often physically frozen in specific situations such as school or when she is out with her family.
This affects her ability to join class activities and make friends at school. Other typical childhood experiences, such as attending birthday parties or joining in after-school activities, prove to be challenging for her.
Belle has selective mutism, which affects about one in 140 children under the age of eight years.
Selective mutism is an anxiety disorder characterised by a consistent pattern of silence in specific social situations where speech is expected (for example, at school or work) while the person is able to speak comfortably in other situations (such as at home with close family).
To receive a diagnosis, this pattern must persist for over a month and cannot be explained by another communication or psychiatric condition. This lack of speech affects the person’s education, friendships and work.
Selective mutism usually starts between two to five years. Although the condition becomes less common in adolescence and adulthood, if left untreated, it has a significant effect on the person’s mental health, wellbeing and life opportunities as an adult.
No one cause
There is no one cause of selective mutism. Instead, it is developed by the interaction of several risk factors such as the person’s genes, temperament, brain development and environment. So each person with selective mutism is different.
In 2011, researchers at the University of California found that the same gene linked to autism, language impairment and anxiety traits is also associated with selective mutism. Parents often report a family history of anxiety or communication difficulties, which supports this.
Children with selective mutism often display what is known as a “behavioural inhibition” temperament. People with this temperament tend to show fear and avoidance of new people, situations and objects. These children often avoid taking risks, which can hinder progress during treatment, since social communication and interaction involve taking risks.
Researchers have suggested that some children’s lack of speech may be reinforced by significant people in their environment, such as family members and teachers.
The authors of The Selective Mutism Resource Manual, used by many therapists in the UK, suggest that when these significant people pressure the child to speak or allow communication avoidance, they are maintaining a selective mutism environment.
In Belle’s situation, there were two parts to her treatment for selective mutism. The first part was a systems approach, which addressed the environmental factors that maintained the selective mutism.
The systems approach involved training her parents and teachers about selective mutism and how to support her communication in everyday situations. They were asked to adapt their communication styles with her to take away the pressure for speaking and yet create opportunities for her to communicate verbally and non-verbally.
They were also asked to address any situation where people put pressure on her to speak (for example, school dinner staff insisting she speak to order her food) or where she was criticised for not speaking (for example, grandparents saying that she was rude).
The second part of Belle’s treatment used a behavioural approach involving a small steps exposure and reward programme. The exposure technique used in the programme was “sliding in”, also known as stimulus fading.
During a sliding-in session, Belle and her mother comfortably played and talked in a room at school. The year one class teacher who had never heard Belle’s voice was introduced in small steps to the activity while Belle remained comfortable enough to continue talking. The small steps progressed from Belle using her voice in front of her teacher to eventually speaking to her.
Belle continued to make progress by slowly introducing new people in different situations. She was involved in every step of the treatment, which helped her feel more confident and in control of her anxiety.
My colleagues and I systematically reviewed the literature on selective mutism treatments without medication. We found that children who received treatments using a combined systems and behavioural approach, similar to Belle’s experience, made significant improvements in their speaking behaviour than those who had no treatment. These treatments involved a therapist, parent, teacher or camp counsellor, and the child.
In Belle’s case, she was talking to children in the local park within a year of starting the treatment. She was contributing to class discussions and being her playful and boisterous self in the school playground. And she started making friends in her local gymnastics club.
*To ensure anonymity, Belle is a composite of various children I have treated for selective mutism.
For more information on selective mutism, access the Selective Mutism Information and Research Association (Smira) website. For adults with selective mutism who want to connect with a community for support access the iSpeak.org.uk website or search SM Talking Circles.
Gino Hipolito receives funding from the National Institute of Health and Care Research (NIHR) Clinical Doctoral Research Fellowship (NIHR302167). Gino also works for St George's University Hospitals NHS Foundation Trust as paediatric speech and language therapist. The views expressed are those of the author and not necessarily those of the NHS, NIHR or the Department of Health and Social Care.