Affordable, ‘ice-breaking’ interventions such as those described by Roe (1993, 2004) and in Chapter 9 of this volumeCHAPTER 17
Summary and Recommendations for the Future
What has been learnt from the contributors?
We have seen in this volume that attitudes and beliefs around children who fail to speak in specific situations have changed over the decades. These children do not form a homogeneous group. The term ‘Selective Mutism’ (SM) identifies their behaviour rather than their disorder. Viana et al. (2009) felt that a developmental psychopathology perspective, contrary to an ‘either/or’ view, might be particularly helpful when considering the complexities of SM (p.65). However, it is now known that the great majority of these silent children suffer from an anxiety disorder and can also have additional problems which require attention (Yeganeh et al. 2003). Parents have presented us with new information about their SM children and we have also heard from some of the children themselves. We have seen that concerns about children affected by SM are leading parents and professionals to set up effective support groups, both here in the UK and abroad.
Diagnosis of SM has sometimes been complicated by ‘exclusions’. Whether it is helpful to say that a child with an additional diagnosis should not be described as having SM may depend on local policies. We were pleased to be able to include chapters discussing ‘co-morbidity’ of SM with communication disorders and the autistic spectrum.
Another chapter described how medication may have helped a young man who is now free from SM, and a child psychiatrist discusses this topic further.
We were grateful to the local authority workers who explained how services offered in community settings helped individual children to begin, in some cases quite rapidly, to talk at school. A music therapist later showed how similarly rapid results can be obtained. We would like to stress, however, that quick cures are not necessarily permanent. Some children need ongoing support to prevent relapse, especially at transition points – for instance, when they face a change of school or teacher.
In another chapter, parents, children and young people described how, with the support of SMIRA, they overcame SM very gradually, step by difficult step – in some cases permanently.
Details of the administrative arrangements for providing services for SM and the legal framework that supports these services in the UK were provided. Also, for comparison, we included descriptions of the SM situation in some other countries.
The vital related issue of confidence was discussed, towards the end of the book, by a specialist who has been providing classes to promote this for children and adolescents in schools and colleges over many years with excellent results.
The recovery of two young adults by means of personal determination, consultation with SMIRA and the establishment of friendships within the peer group was described. In contrast to these achievements, a valuable appendix (see page 272) describes a research project exploring the situation and views of adults, many of whom were not helped as children and did not have the same opportunity to put the problem of SM behind them.
In this final chapter we suggest some possible future developments. Key messages from the previous chapters have been that many SM children long to communicate and will respond to sympathetic (but not overindulgent) guidance. We know what type of help is available and we know that it should be offered at the earliest possible stage, so that SM children’s anxiety does not go on to become a lifetime burden.
Understanding anxiety
A significant contribution to the understanding of anxiety and SM has been made by Rachel Klein, Professor of Clinical Psychology, University of New York Child Study Centre. She had been a member of the Review Committee which was set up during the preparation of DSM-IV which was the previous version of DSM-5 mentioned throughout this book.
The committee’s recommendation at that time was that the disorder previously known as ‘Elective Mutism’ be renamed ‘Selective Mutism’ since no evidence was found that situationally silent children had a deliberate preference not to speak (personal communication 1992). It was also noted that the majority were very anxious.
Professor Klein is the author of a most informative paper (Klein 2009) introducing the classification of anxiety disorders current at that time.
It may be helpful to clarify the meaning of ‘anxiety’, which is an emotional state maintained in anticipation and preparation for future imagined events. An anxiety state is complicated by many factors, some internal and others external. It is related to ‘fear’, which is a simpler, more direct response to current danger, preparing the body for fight or flight.
SM is now much more widely acknowledged to be an anxiety condition and many speech and language therapists and teachers have understood that some SM children may be making unconscious use of what is known as a ‘safety behaviour’ to deal with overwhelming anxiety. Confusingly, careful observation of an SM child may lead one to the false conclusion that s/he is simply choosing not to speak and is not feeling at all anxious. This observation can lead to impatience and criticism when the crucial piece of information previously mentioned in our introduction and in Chapter 15 is missing, that is, by avoiding verbal interaction in anxiety-provoking situations, children can feel relatively comfortable. They have successfully sidestepped their worries. People who fear they may stammer sometimes achieve a similar result by means of ‘avoidance’ – for instance, by keeping utterances short or substituting safer choices for difficult words thus concealing their difficulty.
Sweeney et al. (2013, p.90) state: ‘Avoidance is anxiety’s best friend. Avoiding feared situations permits the anxiety to further develop and become more fully integrated into one’s life. The skills taught in psychosocial treatments are in service of facilitating the individual’s engagement of the feared situation in order to neutralize and extinguish the fear.’
Is there a genetic explanation?
There is now general agreement that SM may be related to social phobias and that there is often a family history of shyness, or avoidance.
In 2007 an internet questionnaire was given through SMIRA to parents of SM children, and 53 members replied. Thirty-eight were parents of girls and 15 of boys. Forty-seven individual parents reported a history of family shyness. This ratio confirms literature reports (Cline and Baldwin 2004; Roe 2011). However, it is thought to be an oversimplification to ascribe complex behaviour patterns purely to genetic factors. The environment and family lifestyle that children are exposed to from the very beginning is known to exert a major influence. Also, the child’s inborn temperament will play a part. As mentioned in Chapter 10, some children show ‘behavioural inhibition to the unfamiliar’ (Kagan and Snidman 2004). It was found that this applied to 10–15 per cent of newborns.
A recent paper describing parenting interventions for young anxious children (Laskey 2011) stresses the need to investigate how parents manage stressful interactions and also how they react to their children’s anxiety. Laskey’s view is that both overly rigid and overly lax parenting have the potential to increase a child’s vulnerability to anxiety. A rigid upbringing can undermine a child’s autonomy and confidence to try new experiences, while lax parenting can deprive children of the supportive structure which is needed to discourage avoidance.
It also seems possible that anxious mothers have a tendency to overprotect their children. Aktar et al. (2014) found that the babies of mothers with lifetime diagnoses of Social Anxiety Disorder (SAD) became progressively more afraid of strangers. At 30 months they showed higher levels of fear and avoidance than the children of mothers without this diagnosis.
The findings in Aktar’s research were specific to SAD, but there could also be an association with SM. Families might therefore like to consider seeking help for their own discomfort, not just that of their child.
Where should help be offered?
Another concern of Rachel Klein’s was that children with anxiety disorders were not being referred. At that time, she noted: ‘The majority of children with anxiety disorders are not referred for treatment. To enable identification and treatment of children with anxiety intervention will need to be implemented in non-psychiatric settings such as schools and Primary Health Care settings’ (Klein 2009, p.158).
Up to a point, this is also the position of the editors with regard to SM. Schools will often be the places where effective, long-term help can best be organized and parents supported, though schools may not always be fully prepared for this responsibility.
Since 2007, schools in the UK have had a duty to foster their pupils’ mental health as well as their academic development. A succession of government initiatives have sought to include emotional health and development in educational objectives. One such initiative is the Targeted Mental Health in Schools Project (2008).
However, when Vostanis et al. (2013) conducted a baseline study looking at schools’ capacity to undertake this additional duty, shortcomings were found. Five hundred and ninety-nine primary schools and 137 secondary schools were approached and it was found that, although two-thirds of the schools did focus on all aspects of the children’s mental health, they concentrated on reactive rather than preventive interventions. Support for teachers in this new role in the form of consultation, counselling and training was limited. The editorial of the publication in which the Vostanis study appeared (Weare 2013) is forthright in pointing to the central importance of adopting preventative approaches, which necessitate improvements in staff support, morale and preparation.
Unfortunately, anxious children in need of help are often seen by organizations isolated from one another and there is at present little co-ordination, joint funding or information-sharing between schools, Social Services, Community Health and CAMHS. This may particularly apply to very young children who are at the stage where intervention is likely to be most successful.
Despite this, we suggest that a fruitful approach for SM might be the greater involvement of CAMHS teams. An advantage of this could be that Cognitive Behavioural Therapy (CBT) would become more readily available.
What types of intervention can be recommended?
Commenting on prevention and treatment, Klein (2009) stated that substantial progress had already been made by using systems such as CBT, possibly combined with medication. CBT aims to change children’s anxious thinking and also the thinking of their anxious parents. It also aims to reduce their fearfulness by encouraging them to alter their behaviour by very small steps. Where SM is concerned, the therapist or helper needs to understand in considerable detail just how complex successful communicative behaviour actually is, so as to be able to break it down into sufficiently small units. The absence of these minute graduations of difficulty may explain why CBT, given alone, has not to date recorded great success with improving the actual communication of SM people, although their anxious thinking may well have been brought under control. Another factor may be that the therapists have found it difficult to deal with non-speaking patients.
Speech and Language Therapists (SLTs) are often able to provide the detailed breakdown that is needed (see Johnson and Wintgens 2001 and also Katz-Bernstein in Chapter 12 of this volume) while parents, teachers and learning support assistants are in an excellent position to put it into practice day by day (see Chapters 9 and 10 of this volume and also Robinson and Burges 2001).
It is relevant that Law and Garrett (2004) suggested that, in view of the relationship in childhood between speech–language–communication and behavioural difficulties: ‘There is clearly a case for integration of the provision to these children and this should be reflected in clinical guidelines and good practice recommendations’ (p.54). A strong emphasis on co-operative preventive SLT policies can also be found in Law, Reilly and Snow (2013).
As people who often gain detailed knowledge of the ‘small steps’ approach to restoring actual speech, parents can play a vital role in delivering more effective, holistic CBT to SM children. Studies in the past have shown that there may be a significant reduction in children’s anxiety when intervention is delivered by their parents, guided by therapists. A recent randomized control trial undertaken by a group of clinical psychologists (Thirlwall et al. 2013) involving 194 children found that parents who were supported and guided to use a self-help book (Creswell and Willetts 2007) and CBT to reduce their children’s anxiety achieved excellent results. In this particular study the parents did not themselves have diagnosed anxiety disorders. We need to acknowledge that parents who are themselves anxious will find it understandably harder to encourage their timid children to face life’s challenges. Murray et al. (2008), for example, found that, unfortunately, anxious mothers tended to encourage avoidance in anxious children, thereby increasing their vulnerability. Consistent and ongoing support and encouragement for the whole family may be the key. A very useful handbook From Timid to Tiger has been produced by Cartwright-Hatton et al. (2010) for professionals aiming to support anxious parents. The light-hearted, yet sympathetic, tone of this book makes it particularly suitable for helping families where a timid and avoidant approach to life has become an unintentional habit.
Avoiding negative adult input
We have seen that teachers and nursery staff are viewed as crucial by people who have suffered from SM. Stories of their struggle with the condition often focus on terrifying experiences with these powerful adults or on lifelong gratitude to heroic rescuers from among the same group. The adults in our Appendix also describe teachers as having been important.
The little girl whose fictional account of SM (Johnson and Wintgens 2012) inspired us to begin this book devotes nine pages to teachers and asks them, above all, to be understanding. Unfortunately, this is not always easy. Few confident people can imagine what it feels like to be unable to respond when expected to talk. On the other hand, most of us fully sympathize with the feelings of hurt, frustration and impotence experienced by the person on the other end of the silence. Therein lies a problem for situationally mute people; they are frequently criticized but seldom understood. Indeed, even the professional view of their silence was at one time highly critical. We have seen that they were labelled ‘Elective Mutes’ and were widely perceived as ‘speech refusers’, manipulative, rejecting, controlling and hostile. Unsurprisingly, their condition was then regarded as intractable, since indignant demands for speech serve only to increase situational anxiety.
The fact that we now know better does not always bring our hurt feelings under control when children appear rudely silent, though it should.
What should now be done to improve the lives of children and families where someone is selectively mute?
•Diagnostic exclusions which prevent SM children from accessing services should be ignored. Professor Sir Michael Rutter (2008, p.211) stated in the context of language disorders, diagnostic concepts and risk processes: ‘Fortunately, in the United Kingdom most services do not operate in a “tick box” diagnostic fashion… On the other hand, some services unfortunately do have a tick-box approach, and for them it is reasonable to use the label that provides an entry ticket.’ We take this to mean that common sense should be applied.
•The availability of information about SM should be improved. Reaching the relevant professional groups as well as parents and carers is essential. National guidelines, similar to those available in relation to autism, would improve the identification, handling and remediation of SM.
•The National Institute for Health and Care Excellence (NICE) has been asked to consider recommending early assessment and intervention for SM children in order to safeguard their mental health.
•The evidence base concerning management and remediation of SM needs to be strengthened. Experience has shown that several types of intervention for SM can be successful and several studies in the past supported this. Recently, a randomized controlled trial conducted in Norway (Oerbeck et al. 2013) confirmed that good progress can be expected, especially if help is offered at an early age. We would add ‘or at a time of emotional readiness’. However, the evidence base still needs to be strengthened. The need for follow-up and ongoing support also requires investigation. As shown in Chapters 9 and 12, children who have suffered from SM are apt to experience any major life-change as challenging.
•Researchers may like to consider projects concerning the efficacy and cost-effectiveness of the following approaches:
Affordable, ‘ice-breaking’ interventions such as those described by Roe (1993, 2004) and in Chapter 9 of this volume
Parent-assisted, step-by-step behavioural treatment as described in Chapter 10
Combinations of either of these with CBT therapies
Pet/animal support for SM children
All types of music therapy for SM
Intervention strategies for SM in adults.
Further research questions
•What is the true incidence of SM? We suspect that it is more prevalent than was previously thought, as do Sharkey and McNicholas (2012). These child psychiatrists share Klein’s impression, referred to above, that not all SM children are referred for treatment, but also identify some of the factors that make it difficult to gain reliable information about the incidence of this disorder.
•Are there selectively mute children without recognized anxiety disorder? If so, what may account for their silence and what kind of help do they need?
•Does recognition of sub-groups within SM yield more reliable information than treating it as a unitary phenomenon?
Our primary recommendation
The development of a young child’s situational silence into a costly and harmful long-term condition appears to be most easily avoidable if it is tackled early. However, in Chapter 2 of this book Tony Cline points out that ‘There are no published data on the incidence of SM in nurseries and playgroups. Relatively few referrals are recorded’ (from those settings).
We would therefore like to see all health visitors, social workers and nursery staff receive basic training in the recognition and initial management of SM in young children, with special attention being given to appropriate parent guidance and support. Some primary school and nursery staff should receive more advanced training in remedial approaches to SM.
GPs, paediatricians and service commissioners, psychiatrists and psychologists need access to reliable information about SM, as do families and the wider children’s work force.
Commissioners in particular will then be in a position to embark on preventive joint commissioning (health/education/social care) in one of the areas of child mental health as recommended by the campaign group Young Minds (Brennan 2013).
Together with parents, the people identified above can ensure that environments are adapted so as to be less overwhelming to the anxious child. In a nutshell: the demand for speech must be discontinued and non-verbal communication and noisy play, within and beyond the home, must be encouraged. Facilitation groups such as that described by Roe (1993, 2004) also have a part to play. Having said this, we hope to have shown that some children – for example, Ann in Chapter 10 and the two formerly SM adults in Chapter 16 – need time to mature before their SM can be overcome and that success can be achieved at later stages, given the requisite information, motivation and support.
We hope the book will help to release some previously unheard voices.