Speech and language: Selective mutism

Selective mutism, previously known as elective Mutism  describes children who are able to talk quite freely in some situations, for example, with their families at home, but who have been persistently silent in other situations.

Selective mutism is not shyness or stubbornness, it is a psychological problem, often with no identifiable cause. Children with selective mutism seem to freeze and become unable to speak. It is sometimes referred to as a social anxiety or a phobia of talking. 

It is a rare condition and usually reported between age 3 to5 years. More girls than boys are affected, and bilingual children and those with other speech and language difficulties are also slightly more likely to display it. 

It can be hard to distinguish between these children and those who are exceptionally shy. Shy children will gain confidence and start to interact over time, whereas children with selective mutism will remain silent and not acknowledge interaction attempts. 

Be aware that children who are learning english as an additional language often go through a silent period. This is not selective mutism, they are just taking time to acclimatise, to begin to tune in to the sounds of english in the setting, and to learn what is expected before they have the confidence to try out the language themselves. 

Features of children with selective mutism may include:

• finding it difficult to make eye contact when they are anxious. They may turn their heads away and ignore you. One might assume they are being unfriendly, but they are fearful and just do not know how to respond. 
• looking blank, frozen or expressionless when anxious. In nursery or school they will be feeling fearful most of the time, which is why it is hard for them to smile, laugh or show true feelings, even when they have a wicked sense of humour. 
• moving stiffly or awkwardly when anxious, or if they think they are being watched
• clinginess
• stubbornness or aggression, having temper tantrums when they get home from school
• finding it difficult to answer the register or say hello, goodbye or thank you. This can seem rude or hurtful but is not intentional. 
• slowness to respond to a question
• worrying more than other people
• sensitivity to noise, touch or crowds
• intelligent, perceptive and inquisitive

Intervention for children with selective mutism must be carried out with extreme sensitivity and often progress is very gradual. The approach commonly recommended is a step-by-step behavioural 
therapy programme (described in several of the resources listed) to be carried out by a key worker that the child feels most comfortable with in the setting.

The earlier this can be started, the better. If left untreated, behaviours can become entrenched and persist into adulthood. Treatment effectiveness depends on how long the child has had selective mutism, their age, whether they have additional difficulties, and the cooperation of all involved with the child.

Staff in the setting should all familiarise themselves with what selective mutism is, and there is a helpful video called ‘Silent Children’ which could be watched as a team for this purpose.

It is understandable that practitioners might feel anxious, but try not to let the child sense this. Ensure you have time to discuss your anxieties about the child to your manager/SENCo.

Key messages:

• Expect less, support more
• A consistent and trusted key adult in the setting to work with the child. Building this relationship will take time.
• Build on situations where the child shows strengths
• Have lots of patience; progress is often slow
• Different strategies work with different children
• Work together with the child’s family (with child’s consent). Meet to share strategies, progress and ensure a consistent approach.

• If the child does not answer the register verbally, allow them to acknowledge their presence in other ways, for example, smile, nod, look, or raise a hand
• Let children point to their selection at lunchtime or to pictures in the classroom. There should be no pressure to talk until they feel ready.
• Avoid the dread of turn-taking in circle-time activities by asking who would like to say something, rather than waiting for each child to have a go
• If children do not naturally speak out in circle time, help them contribute by doing something rather than talking. They can hold a clip-board, give out cards, show something they have brought from home. 
• Discuss with the family whether it would be appropriate for them to record videos clips of the child talking at home and let the child play them in the setting (with child’s consent)
• Provide symbol cards and pictures fans with key messages on
• Encourage thumbs up or down to check if they understand
• Older pupils can write answers down on a notepad
• Whiteboards are useful as you can quickly wipe something off so that it’s not permanent (like speech)
• Visual timetables can provide a visual support for interaction and help reduce anxiety

Encouraging interaction 

• Do not pressure the child or bribe them to speak. Instead, model talk during play.
• Ensure other children are not accidentally undermining the efforts of the staff
• Gently discourage others from speaking for the child
• Encourage, and reward all attempts at communication by the child, but don’t make a fuss or show surprise as this can cause embarrassment
• Make chatty or admiring comments, rather than asking questions
• It is important to create an accepting and rewarding atmosphere in which the child feels comfortable, whether or not they talk
• Sometimes sit the child at the front of the group for a story, to encourage attention and involvement
• Use activities and games that don’t require verbal interaction e.g. puzzles, ball games
• Provide a quiet place or time to meet regularly, for example, library or cosy areas, ‘haven’ club, pastoral room
• Find out the child’s hobbies, interests, likes and dislikes—these are a good starting point for conversations
• Use humour
• Let the child choose the area where they feel most comfortable working
• Stand back when the child interacts with other children. Often they speak more without an adult present or watching.

Developing self-confidence and esteem

• Never talk about the condition in front of the child
• Let them know you understand they find it hard to speak sometimes. Reassure the child that it’s ok if they don’t feel like talking just yet, there’s plenty of time.
• Encourage self-expression through open-ended creative, imaginative and artistic activities, which have no clear expectations
• Every achievement by the child should be praised and rewarded
• Give extra smiles and attention when children try anything new. Do things with the children or make things easier, rather than doing things for them.
• Any form of non-verbal communication from the child should be accepted and encouraged, for example, smiling and waving as this helps to build the positive relationships which are so vital in overcoming this problem.
• Parents can reduce the anxiety of separation by giving the child something of theirs to look after before they leave. Consider an early return so that a parent can join in and make the last part of the morning/day a positive experience. Welcome parents as volunteer helpers in their child’s class.
• Include more activities where children talk, move or sing together for support

Other treatments you may read about

• Medication is not appropriate for younger children and is only used in a few cases for older children whose anxiety has led to depression and other problems. Create other activities that involve use of the voice and oral structures.
• Make noises for toy vehicles and animals in play situations or as sound effects for a story
• Introduce play with puppets, because the child may 'speak' through the puppet, especially from behind a screen. Masks may be helpful. 
• Try non-verbal activities which require expelling air and using the mouth, for example blowing out candles, blowing bubbles, blowing ping pong balls with a straw
• Encourage participation in noisy games and rhymes with predictable language such as 'What's the time, Mr Wolf?' 
• Use activities that focus on the senses to develop the child's self-awareness 
• Sing songs and rhymes
• If the child is socially isolated, link them with other quiet, shy children, (or those that make them laugh/they make a connection with) singly or in small groups
• Play games involving interaction between pairs or the group, such as rolling a ball, rowing boats, ring games and rhymes. 

Having identified a child with features of selective mutism, and considered appropriate strategies to trial, an IPP (Individual Play /Education Plan) should be set up. 

Key messages:

• Involve the child, wherever possible, but without adding to their anxiety
• Discuss with parents what works at home? What could they do at home?
• Do not wait for professional involvement. The SENCo and Key Person should write the IPP together, with support from the parents
• How can the child have a voice in the targets and strategies set? 
• Record positive steps. Ensure the IPP is a working document
• Identify where/who/how/when etc. the child does speak, and start from here
• Ensure all staff members are aware and agree to all of the targets and strategies to be trialled 

How can I make the targets SMART?

• Targets are for the child, not a description of what the adult will do. It might be helpful to start a target with, ‘I can…’ or ‘I will…’
• Targets should be specific, for example, ‘I will show my milk or water visual card to an adult when I’m asked what I want to drink at break every session that I attend.’ A target that is general, for example, I will talk more, is not helpful, specific or measurable.
• Targets should be measurable. This involves setting a specific target that you can measure on each session that the child attends.
• Targets should be achievable and realistic. Does the child have the right resources/right staff/at the right level to achieve the target? Or are you expecting too much?
• Targets should be set within a time-frame. As targets for children with SM should involve small steps of challenge, you might want to consider reviewing your IPPs at a quicker rate than you would other children. Aim for a time-frame within 2-6 weeks.

Example IPP targets

• “I will nod my head when my name is called at register, every session that I attend”
• “I will play and say, ‘snap’ with my mum in pre-school after the session has ended”
• “I will make the animal noise for 3 out of 6 animals that I pull out of a bag”

• Selective mutism in children. Cline, T & Baldwin, S (2nd edition 2004), London: Whurr
• SMIRA (Selective Mutism Information and Research Association). Lots of useful resources in the ‘downloads’ section. Tel: 0116 212 7411
• The selective mutism resource manual. Johnson, M & Wintgens, A (2001), Bicester: Speechmark Publishing
• Silent Children: approaches to Selective Mutism, 24 minute film. Available on VHS or DVD from SMIRA.
• Silent Children: approaches to Selective Mutism. Sage, R. & Sluckin. Available on SMIRA.
• Johnson, M., Wintgens, A., and Gallow, R. (2012). Can I Tell You About Selective Mutism?: A Guide for Friends, Family and Professionals. Jessica Kingsley Publishers.
• Johnson, M. and Jones M. (2012). Supporting Quiet Children: exciting ideas and activities to help ‘reluctant talkers’ become confident talkers’. Lawrence Educational.
• Sluckin, A. and Rae Smith, B (Editors) (2014). Tackling Selective Mutism: A Guide for Parents and Professionals. Jessica Kingsley Publishers
• NHS Advice
•  iSpeak

If you have implemented this advice and are still concerned, then consider if you need the support of other professionals.

Should we refer to speech and language therapy?

A referral to speech and language therapy is only recommended when children are persistently not talking in a setting for 4 half-terms/6 months and are also thought to have speech and language difficulties.

Our role with respect to reluctant talking would be to determine, as far as possible, whether there is an underlying difficulty with speech, language or fluency. We can assess their understanding of language through tasks where they are just required to point or move toys around, but it is obviously more challenging to assess their spoken language and speech sounds.

It is often useful if parents/carers can provide a tape/video of their child talking at home instead.

Should we refer to educational psychology?

If a child is persistently not talking in a setting for two terms (6 months), discuss prioritising the child for Educational Psychology involvement with your link Educational Psychologist . This will help establish the possible cause of a child persistently not talking. Educational Psychology can help you establish if onward referral is needed to other services.

Should we refer to targeted mental health?

Children’s mental health services may become involved after speech and language therapy or educational psychology have assessed the child and recommended a referral.

Please note: None of the above services usually diagnose selective mutism, but they will identify if a child is showing features of it. If a setting or family wanted a diagnosis, a referral would need to be made to the paediatricians through the GP or a practitioner, which may include a multidisciplinary assessment involving the above mentioned professionals.