CHAPTER 1
Introducing Selective Mutism and an Overview of Approaches
This book was conceived as a companion volume to a fictional book published by Jessica Kingsley Publishers: Can I tell you about Selective Mutism? (Johnson and Wintgens 2012). This was written by two specialist speech and language therapists from the point of view of a fictional selectively mute child, and it reveals much of what children have told their helpers over the years.
The chapters of the present book have been collected in response to some of the needs of such children and their families.
Selective Mutism (SM) is a relatively rare and, until recently, little understood emotional disorder of childhood. These children converse fluently with intimates, usually in the privacy of their home, but do not speak in unfamiliar environments to people they are not familiar with, even sometimes those related to them. Much more rarely a child may speak outside the home but not within it. There is evidence in the literature (Cline and Baldwin 2004, pp.44–5) that a small minority of SM children have experienced some form of abuse or rejection in the home. Most SM children don’t speak at school to their teacher or peers, but may collaborate in classroom activities non-verbally and communicate by gestures, although some of them even have difficulty making eye contact and can appear withdrawn and defensive.
In the past these children were thought to be stubborn and contrary, but more recent research indicates that the majority of them are anxious (Johnson and Wintgens 2001; Cline and Baldwin 2004), a view that official classifications now recognize.
There is speculation that, for some individuals, overwhelming anxiety may even result in temporary paralysis of the larynx, and it is beyond doubt that many who appear superficially calm are avoiding anxiety by avoiding speech.
Alice Sluckin now describes SM on the basis of her lengthy experience
As one of the editors of this book, I would like to share with you what I learned about SM while helping such children and their parents and working over many years in a clinical setting. I hope this introduction will also contribute to a better understanding of the chapters written by parents about their SM children and of those recovered sufferers in the text. Next I want to tell you more about the SM child’s problem within his/her family.
Parents coping with an SM child
Parents often first notice SM when the child enters a nursery at the age of three. Since it is a relatively rare condition, thought to occur in approximately one per cent of the population (Bergman, Piacentini and McCracken 2002), misdiagnosis of separation anxiety may be made. Parents may describe some of these children as being shy and timid, but also at other times as noisy and non-compliant and also oversensitive to noise and touch, as well as unable to tolerate a change of routine. There may also be problems at bedtime.
Parents may find the child difficult to manage, particularly as they may not have come across another family with an SM child before. The family’s health visitor may refer the child to the local general practitioner (GP) who hopefully might recommend referral to a speech and language therapist (SLT) and psychologist. The earlier the better, so that medical, neurological and cognitive problems can be excluded and possible co-morbidity (co-existing conditions) explored.
Unless SM is recognized early it can become entrenched, and in time will seriously interfere with the child’s social, emotional and cognitive development.
What causes SM?
No single cause has been established. Research points to the presence of genetic factors (Cline and Baldwin 2004), as SM is more likely to occur if there are other members of the family showing similar behavioural traits.
A child’s inborn temperament may also play a role in causation. Kagan and Snidman (2004), two internationally known researchers into biological and neurological aspects of innate childhood temperament, observed that 10–15 per cent of all newborns may be having problems with regard to adapting to unfamiliar people as well as being unable to face change. They called such children ‘behaviourally inhibited to the unfamiliar’. When tested at four weeks and retested at 11 years they were more likely to be found shy and timid. It is possible that some SM children belong to this group.
There is international agreement that girls are more likely to be affected (Wright 1968; Cline and Baldwin 2004). Very bright children as well as children with learning disabilities can become selectively mute. Speech delay has been found to play a significant part in causation (Kolvin and Fundudis 1981). The condition is more frequent in ethnic minority families (Brown and Lloyd 1975; Cline and Baldwin 2004). Also, twins are more prone to SM (Wallace 1986). Frequent moves and isolated living may be factors, as well as an unsettled home background.
The SM child in the classroom
Often the SM child does not answer the register, does not read to the teacher and does not talk to peers. At mealtimes s/he does not say ‘Please’ or ‘Thank-you’ as requested by the dinner lady, and there may be problems over going to the school toilet.
Margaret Buck (1988) was one of the first teachers to draw attention to SM, and made very useful suggestions as to how such children could be helped. She pointed out that a classroom is a language environment, and she regarded talking as the pre-eminent instrument of learning. Hence the teacher who fails to establish communication with a pupil can feel inadequate and become frustrated and angry.
An example of how even a very experienced teacher might react with frustration or even despair to a non-responding child is described in the Times obituary (08.06.2012) of Elizabeth Manners, late Head Mistress of Felixstowe College, Suffolk. The obituary quotes Dame Elizabeth’s comments on interviewing Lady Diana Spencer, later Princess of Wales, who had applied for admission to her college. The interview went as follows:
She (Diana) just sat there with her head drooping. I said to her that, if she were to attend Felixstowe College, she would have to speak to me and I would have to see her face, but her head drooped further. There was nothing I could do.
Fortunately, many more teachers are by now able to deal confidently with SM children. Alison Hall, an experienced teacher, describes how she taught a 10-year-old boy to speak to her and read to her, though he had never spoken in school before (Hall 2008).
Diagnosing a selectively mute child
The criteria to be used for diagnosing SM children vary in different documents. However, it is widely agreed that the simple fact that a child is known to speak confidently in some situations while remaining consistently silent in others where speech is expected is sufficient for a child to be regarded/diagnosed as SM, provided that the child is not in their first term at school or in a new country in the first six months of learning a new language. More complicated diagnostic approaches are seen as potentially misleading, since the affected children differ from one another and may well have overlapping conditions, which need to be recognized and treated alongside the mutism.
More formal diagnostic recommendations include the following:
•The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5) (APA 2013) has once again updated its view of SM. Previously APA (1994) classified SM in the section ‘Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence’. It is now classified as an Anxiety Disorder, given that the large majority of children with SM are anxious. The diagnostic criteria are largely unchanged from DSM-IV.
•The ICD 10 (International Classification of Disabilities) (WHO 1994, update due 2014). This manual is widely used in the UK. It now adopts the term ‘Selective’ rather than ‘Elective’ Mutism as previously, and categorizes it under ‘Fear and Anxiety Related Disorders’ in its ‘Mental and Behavioural Disorders’ section. The question of comorbidity and possible exclusions from the diagnosis of SM is still under discussion.
•The UK NICE (National Institute for Health and Care Excellence) Guidelines, constantly in the process of being updated, now include SM as an additional or associated diagnosis rather than, as previously, a variant of social anxiety disorder (2014, p.76 and p.253). A variety of alternative forms of communication are recommended for reluctant speakers (p.79 and p.242).
It is sometimes stated that children with other disorders of communication might be excluded from a diagnosis of SM. Our view is that this can be an unhelpful exclusion, as the conditions overlap. Both difficulties need to be tackled together using a team approach.
Helping children to overcome their fears and helping parents
As was said before, the problem of SM is not a new one. Joan Tough (1976), a highly respected English educationalist, when referring to children not speaking at school thought that mutism was usually due to a number of causes, but leaving the child on their own for long periods hoping that he or she would in time begin to approach and talk to others was likely to make it more difficult. In her view, the child would then adopt a role or position from which it would be increasingly difficult to escape.
It is now realized that the prognosis with regard to recovery from SM is much more promising if treatment commences at an early age, before the child acquires a non-speaking identity and is being treated as a non-speaker by peers and teachers (Johnson and Wintgens 2001; Roe 1993, 2004).
Although most children outgrow SM, sadly it can follow some into adulthood, as can be seen in the Appendix.
Until the 1950s, the treatment of SM was largely influenced by misleading psychodynamic interpretations of the condition, which blamed difficulties in the mother–child relationship, but ignored the children’s inability to speak with strangers. At that time it was not understood that the child, by not speaking, was probably avoiding being devastated by feelings of anxiety.
From the 1960s onwards there was a radical shift to a new orientation in psychology toward Behaviour Modification, an approach based on the principles of learning and developed after experiments with animals. These had shown that fears and phobias were, in many cases, learned by an individual in vulnerable situations and could be unlearned (Herbert 1959; Marks 1969).
An English educational psychologist was the first to propose that SM was learned; he also noted that such children were very anxious (Reed 1963). To understand the condition better, parents were encouraged to keep records of the child’s frequency of talking to specific people in specific situations. Nor was the condition any longer perceived as primarily controlled by the affected child, but was one that was strongly influenced by the response of others. Thus Cunningham et al. (1983) observed that, in response to children’s silence, teachers often adopt a pattern of verbal interaction (for instance, questioning) which reinforces their silence, while peers in contrast ignore them. Hence it was realized that parents and teachers were key people in the management and treatment of SM. The use of behaviour modification strategies in the treatment of SM became even more accepted after the seminal paper by Black and Uhde (1995). Thirty SM children ranging in age from 5 to 16 were studied, and it was found that their characteristics resembled children suffering from a social phobia and avoidance disorders.
When devising a behavioural programme, achievable intermediate targets must be set to enable the child by very small steps to move through non-verbal communication to speech, as the child’s level of anxiety gradually decreases. If necessary, a behavioural approach can be combined with the use of puppets, play and music therapy, or ‘cognitive-behavioural’ guidance in the case of older children.
Behavioural strategies that are particularly successful in counteracting anxiety are fading and shaping:
•Fading, colloquially known as ‘sliding-in’, is used as a starting point in a situation when the child is relaxed and talking to a familiar person, usually a parent. Another person then enters the room but stays at a distance. Gradually, step by step, the new person moves nearer. Depending on the child’s reaction, this can take a long time or desensitization can come about quickly. Once the new person is accepted by the child s/he becomes the main helper and the parent is faded out.
•Shaping consists of rewarding any sound s/he might be making by mouth such as blowing bubbles and windmills, or imitating animal noises. This is attempted if during a programme a child remains totally silent, in the hope that it will gradually lead to speech. Also, to reduce crippling anxiety, the child is taught slow breathing as well as muscle relaxation (Kearney 2010). Rewards may increase motivation.
School-based behavioural programmes, which rely on ‘small steps’ and gradual exposure of the child to anxiety-provoking situations, have proved very successful (Johnson and Wintgens 2001). Their starting point is when a parent is talking freely to the child in the classroom, another person, who subsequently becomes the key-person, is faded in step by step depending on when the child becomes willing to co-operate with the new person. The programme requires full parental co-operation and a key-worker, who works with the child 4–5 times a week at school for at least one term (Johnson and Wintgens 2001).
Final comments on helping parents and the SM child
Showing empathy to the family and child is crucial (Sluckin and Jehu 1969). For a helper it may be preferable to meet them initially in their home, where both parents and child are likely to be less anxious. The family may also have other problems, monetary or marital, and these should be acknowledged and advice given as to who might be able to assist. If the child is also being seen by another professional, there should be parental co-operation facilitated perhaps by the school nurse (Sluckin 2011) or Special Educational Needs Co-ordinator (SENCO).
There should be a close working relationship between the parents and the school. It is often helpful if one of the parents can spend some time each week at the child’s school, perhaps working on a project suggested by the teacher, possibly in a room adjoining the classroom. Once the SM child has started to talk there, another child can join them, as this might ‘break the habit of a lifetime’.
Prior to starting a programme it is important to make a warm, trusting relationship with the SM child and convey that s/he will be accepted whether s/he speaks or remains silent. Suitable toys in the playroom such as puppets, water or ‘sand-world’ with small figures will create the right sort of atmosphere. If the child cherishes a pet, interest should be shown in it. Pets such as cats and horses have been reported to help a child overcome reluctance to speak, and we shall re-visit this theme in Chapter 10.
Theories of anxiety development in children (Wood et al. 2003) suggest that children’s family relationships and the type of interaction that is modelled at home can be associated with the onset of anxiety, but that the causes and sequence of the condition are complex and elusive. However, one could refer to the following and design treatment accordingly:
•predisposing factors which may be predominantly genetic
•precipitating factors located in the child’s environment which may act as a trigger
•perpetuating factors which relate to the way the problem is being handled in the here and now by the parents as well as the school (Johnson and Wintgens 2001).
Fortunately, there are now, in addition to Johnson and Wintgens (2001), other useful books available on how to help the SM child, giving specific information to parents and teachers. These include Bergman (2013); Davis (2013); Kearney (2010); McHolm, Cunningham and Vanier (2005); Perednik (2013) and Rapee et al. (2008).
Who can help?
You will see from this book that the person helping the SM child may be a professional or a volunteer, such as a member of our charity SMIRA (see Chapter 4). Our experience is that parents are now playing an increasing role in helping one another. However, SMIRA has always taken the view that seriously affected children may need special attention and should be referred to professionals for full investigation and treatment. This is particularly vital when other conditions co-exist.
With regard to predicting recovery, it is impossible to be accurate. but the older the child is at the time of starting a programme, the more likely it is that parents will be in for a long haul!
Rae Smith continues the introduction from another point of view
Speech and language therapists (SLTs) are now asked more frequently to be part of teams tackling SM. They have special contributions to make as they are used to empathizing with speech-impaired clients, facilitating communication in challenging circumstances and identifying speech, language and communication needs (SLCN). Also, SLTs are likely to be adaptable enough to incorporate suggestion and objects of reference into treatment and to assess SM children at home if they fail to speak in schools or clinics (see Chapter 5).
However, when I worked as an SLT I was used to working with children who were completely unable to speak, or to speak intelligibly (Duffy 2005; Smith 2004; Wiesmer 2007), and this led me to feel unsympathetic to SM children. I saw them as contrary and unappreciative of the gift of speech. Also, I had been trained to think that the condition was probably intractable and that treatment should be left to psychiatrists (Smith 2004). It was only through listening to Alice and gaining access to the type of information that is presented in this book that my views changed.
How to use the book
The various chapters have been put together for the benefit of all those whose lives are touched by SM, and it will quickly become obvious that different sections will be of special relevance to different types of reader.
Chapter 2: Tony Cline’s update is likely to interest everyone because of its breadth of view and because he has been one of the foremost experts in the field of SM for many years.
Chapter 3: This chapter presents an important piece of questionnaire-based research, and begins with a section that is primarily intended for fellow researchers. Readers whose interest is more personal will enjoy the chapter more if they begin at a later stage, when the ‘voices’ of families where SM has been a problem begin to be heard. The author is Deputy Chair of SMIRA.
Chapter 4: Anyone with an interest in how support groups are set up, used and developed will want to read this account.
Chapter 5: Co-morbidity means co-existence of various medical conditions. We hope that researchers will find this chapter to be of value. The author is a specialist speech and language pathologist whose colleagues will notice a very useful section on assessment. One of the main messages is that a person who has other communication difficulties may also have SM. Diagnostic exclusions are unhelpful, other than in making insurance-based decisions about professional responsibility.
Chapter 6: Anyone interested in the complex issue of autistic spectrum disorders will value this chapter, which has been written by a specialist SLT.
Chapter 7: This chapter explores the question of whether, or not, SM is related to stammering.
Chapter 8: This chapter is primarily the story of a young man’s recovery from SM, written by a language specialist. Since medication had a part to play in this story, we were interested in dealing with the commonly asked question, ‘Is it useful or best avoided?’ Fortunately, an experienced child psychiatrist agreed to add a comment and a more general further section.
Chapter 9: This chapter provides accounts of how SM has been tackled in schools and beyond by various means. The descriptions are provided by professionals from a variety of disciplines.
Chapter 10: This chapter is written mostly by parents who explain exactly what they did to support their children’s recovery from SM.
Chapter 11: This chapter describes the local arrangements for supporting people with SM in some areas of the UK, which we know will interest administrators and commissioners. International consensus recommendations formed the basis of these ‘care pathways’.
Chapter 12: As its title suggests, this chapter contains a small selection of approaches to SM outside the UK.
Chapter 13: This chapter shows how a music therapy researcher successfully worked with an SM child. Treatment sessions and the theoretical background are described.
Chapter 14: A general issue that pervades all thinking about SM is that of speakers’ confidence. Rosemary Sage has, for many years, been providing and writing about COGs (Communication Opportunity Groups). These have proved helpful to such a wide variety of young people that we were keen to include her insights.
Chapter 15: Written with an education expert, this chapter provides legal and administrative information, which should be useful to people determined to give a fair deal to SM children within the education system and outside it.
Chapter 16: This chapter allows two well-functioning young adults to describe their experience of SM, followed by their paths to recovery.
Chapter 17: Alice and Rae look back at the preparation of the book and at what they have learnt about SM over the years. They also make some recommendations.
The Appendix deals briefly with SM in adults.
People suffering from SM are individuals
Some people think of SM as rather similar to ‘stage fright’ in which competent individuals become nervous about speaking before the public. However, we know that actors usually recover the power of speech once the curtain has risen and it is only rarely that this sort of ‘fright’ prevents them from taking the stage at all. Most of the people who are situationally/selectively mute genuinely find themselves unable or compulsively reluctant to speak in certain settings.
Individuals suffering from SM can differ from one another and may be experiencing differing symptoms, motivation and emotions. A small minority are angry young people who refuse to speak as a form of protest; another minority group have experienced physical or psychological trauma; some are subject to a strong impression of taboo, or are fearful of disclosing dangerous information. Some experience other people, including peers, as hostile and react accordingly. It is now recognized that most would genuinely prefer to interact normally, but some even describe themselves as ‘frozen’ or unable to activate their voice.
Some find even deliberate non-verbal signalling beyond their ability when in a state of terror, but others can achieve communication non-verbally – for instance, through drawing (Miller 2008) and by carrying short messages on cards or miniature recording devices.
It is also important to understand, as Alice has pointed out, that some individuals do indeed remain silent, having learnt that talking is likely to make them feel painfully anxious, but it is by no means certain that they have made this decision consciously. Negative strategies such as this may simply provide intuitive solutions to communication difficulties. Katz-Bernstein (2013, p.25) describes several possible methods of categorizing SM and also points out that a compulsion to avoid speaking can hardly be described as a free choice. It may not be necessary to bring the question of unconscious choice to children’s attention, but awareness of the role of avoidance is a vital insight for their helpers.
Approaches to these differing individuals need to be based on real relationships with the children and their families and, sometimes, on sensitive interpretation of such things as posture, face colour, frowns, sighs or averted eyes, which are truthfully communicative precisely because they are not under voluntary control
One of the challenges for teachers and therapists is that only by honestly acknowledging and examining our own responses can we can begin to guess how silent children might be reached and understood. Unfortunately, one’s own reaction can be quite shaming. As professionals who claim to be positive and constructive in our relationships, we can feel surprisingly cross when children remain ‘rudely’ silent and evasive. A feeling of hurt and rejection is natural in the circumstances, but if this is coupled with a feeling that our professional skills are being made to appear useless, or that we are being disrespected, anger can become part of the mix. Speaking hastily while in this frame of mind to someone who already finds us alarming can only make matters worse. A more constructive response is to muse out loud in an empathetic way, rather than continuing to question a non-responsive child (see box on next page).
‘It seems to me that you may be feeling a bit uncomfortable. You don’t need to talk to me until we get used to one another. We can take our time. You might like to look at what the class is going to study this morning. I’ll just take the register first and mark you present for today. Tomorrow, if you feel ready, we can work out a signal that you can give me.’
Why does SM matter?
First, SM is not age-appropriate behaviour and it can interfere with learning, being included in the peer group and making friends. It can also be very worrying to parents and concerned family members, especially if a child appears to be rude to people such as grandparents. It is true that sociability and quietness are valued differently by different cultural groups and that there can even be advantages to being reserved and being quiet – one gets more work done, for instance – but cutting oneself off from others entirely is not all that enjoyable. It’s a matter of degree.
Gaining experience of making friends, falling out, repairing misunderstandings and so forth helps us to understand how to conduct adult relationships.
Also, there is the question of unpopularity. From time immemorial, casting individuals out of the tribe has been a serious punishment and such phrases as ‘I’m not talking to you anymore’ have signalled rejection and disapproval. This is why people get upset by not being spoken to. If children cannot help being silent, they may need support in coping with other people becoming hostile toward them. It is hard to miss out on the joy of friendships and to be left out of the jokes and plans made by your peer group.
From the point of view of educators, an uncommunicative child can be difficult to assess and to include in class activities. We know of individuals who have been held back inappropriately because of failure to demonstrate their abilities. In another area, Public Health England (PHE) has recognized that engaging poor communicators in public health initiatives such as alcohol awareness or prevention of teenage pregnancies can be particularly awkward.
There is also the question of acquiring social skills. Withdrawing from the arena within which these are gradually put to the test can leave one seriously short of experience. Evidence from parents and people who have recovered from SM suggests that a characteristic of some SM children is difficulty in adapting their style of interaction to unfamiliar situations, where different rules and expectations apply and a different type of understanding is required. Remaining silent when you are uncertain how to behave may well provide an opportunity to weigh things up through observation, but it clearly prevents one from practising the subtle arts of interacting and forming relationships. Any child in this position requires help, but those who also suffer from social communication disorders, sometimes known as ‘pragmatic language impairment’, urgently need specialized attention (Adams 2008).
Pragmatics, that is to say the use and interpretation of language in real contexts, can be an area of difficulty for teenagers who have spent even a part of their school life talking only in comfortable home situations. This is because gaining the ability to handle both the formality of classroom language and the subtle demands of informal social negotiation with peers depends upon experimentation, feedback, trial and error.
Teenage girls, in particular, can get into serious difficulties if they are not able to discern the intention behind what is said to them by boys and men or to make their own feelings and wishes clear.
Young people who have an acceptable appearance and behave in an acceptable manner with peers are not likely to face too much rejection. However, barriers to social inclusion can appear once they begin to speak. A person who has not had sufficient opportunity to practise may have poor timing. They may have difficulty in spotting transition points in conversation, judging whether interruption is possible or estimating how long a turn to take. One has to learn from experience and feedback when to relinquish the floor, when to give ground and when to stand firm, when to be formal and when a casual tone is appropriate. There are skills involved in holding topics appropriately, digressing and returning to a theme, remaining coherent, joking and indicating seriousness. Many factors in addition to the actual words chosen are involved in successful negotiation with other human beings (Cummings 2009; Leinonen et al. 2000; Smith and Leinonen 1992).
Teenagers, for instance, acquire a particular sensitivity to fashions, subtle messages and implications. They value the nuances of slang, ‘bad language’, humour, irony and wit. They pretend misunderstanding to suit their own purposes, they play with language and they always rely upon intonation or non-verbal signals to carry parts of their message. When these skills are weak, relationships with both peers and teachers suffer.
Adams has pointed out (2005, p.182) that at least four aspects of child development play a part in social communication. These are: social cognition (knowledge); verbal and non-verbal pragmatics (behaviour); receptive and expressive language processing; and ‘social interaction’ (experimentation and experience). Ideally, these factors influence one another as children mature and integrate what they have learnt. However, we have the impression that, if social interaction is limited for whatever reason, an individual’s social skills may not develop sufficient flexibility to adapt to the variety of demands encountered in social life or in the adult working environment. It is possible for a silent person to form an impression of how social relationships work by means of observation, but it takes practice to make them work oneself.
For all these reasons, we suggest that SM cannot simply be ignored. This book was written to address some of the issues raised by Situational/Selective Mutism. However, we do not address full mutism, which is the inability to communicate in any setting, having once begun to do so (Lebrun 1990; Magagna 2013) or difficulties in developing any intelligible speech and language at all (Bercow 2008; Bishop 2008; Danon-Boileau 2001; Duffy 2005; Wiesmer 2007). These are different and more severe disorders.