Selective mutism: what it is, signs in children, causes and treatment

Selective mutism is not a refusal to talk. The NHS explains that the expectation to talk to certain people triggers a freeze response, with feelings of anxiety and panic, and talking becomes impossible. People with selective mutism can speak freely to certain people, such as close family and friends, when nobody else is around to trigger the freeze response. The Royal College of Speech and Language Therapists describes it as best thought of as a speech phobia.

The pattern of speaking in some settings and not in others is the defining feature. According to the Royal College of Speech and Language Therapists, the child speaks happily and freely in some situations but not in others, and this has been apparent for a month or more, and the disorder is not due to another communication or language learning difficulty.

Over time a person may learn to anticipate the situations that provoke the reaction and do all they can to avoid them. Without help, the NHS says it can persist into adulthood.

Selective mutism is most often recognised in young children. The NHS says it can start at any age but most often starts in early childhood, between age 2 and 4, and is often first noticed when the child starts to interact with people outside their family, such as when they begin nursery or school.

A child may chat happily at home and then say nothing at school or in a group. The Royal College of Speech and Language Therapists describes two patterns. In the "high profile" pattern the child is totally silent with certain people in certain situations. In the "low profile" pattern the child may manage to speak a little when it is absolutely necessary, but usually does not start conversations with adults.

The NHS says children with selective mutism will often have other fears and social anxieties, and may be wary of anything that draws attention to them because they think people will then expect them to talk. Some avoid eating and drinking during the school day so they do not need to ask to be excused, and accidents or urinary infections can follow if they hold on for hours because they cannot ask to use the toilet.

Left untreated, the NHS says selective mutism can lead to isolation, low self-esteem and social anxiety disorder, and can continue into adolescence and adulthood. This is the reason it is worth asking for help early rather than waiting for a child to grow out of it.

The NHS says the main warning sign is the marked contrast in the child's ability to engage with different people, with a sudden stillness and frozen facial expression when expected to talk to someone outside their comfort zone.

• Avoiding eye contact and appearing nervous, uneasy or socially awkward.

• Seeming rude, disinterested or sulky, or clingy, shy and withdrawn.

• Appearing stiff, tense or poorly co-ordinated.

• Temper tantrums when they get home from school, or anger when questioned.

• Using gestures such as nodding or shaking the head if more confident, or avoiding all spoken, written or gestured communication if more severely affected.

• Speaking in an altered voice, such as a whisper, or managing only a word or two.

The NHS says experts regard selective mutism as a fear of talking to certain people. The cause is not always clear but it is associated with anxiety, and children often have a tendency to anxiety and difficulty taking everyday events in their stride. Many become too distressed to speak when separated from their parents and transfer this anxiety to the adults who try to settle them.

A speech and language disorder or a hearing problem can make speaking more stressful, and some children have trouble processing sensory information such as loud noise and jostling, which can make them shut down. The NHS notes that selective mutism does not mean a person is autistic, as the two are separate conditions, although a person can have both. When mutism occurs as a symptom of post-traumatic stress it follows a different pattern, with a child suddenly stopping talking in places where they previously had no difficulty.

The NHS says early recognition by families and schools matters so they can work together to reduce anxiety. If you suspect selective mutism and help is not available, or there are other concerns, it suggests speaking to a GP and asking for referral to a local specialist service for a formal diagnosis, or contacting a speech and language therapy clinic directly. It advises not to accept the opinion that the child will grow out of it or is just shy.

Diagnosis follows guidelines: the person does not speak in specific situations, can speak normally where they feel comfortable, the inability has lasted at least 1 month (2 months in a new setting), it interferes with functioning, and it is not better explained by another behavioural, mental or communication disorder. A clinician may speak to the parents first, watch the child play or watch a video of them speaking comfortably, and should be willing to find other ways to communicate during assessment.

The NHS stresses that treatment does not focus on the speaking itself but on reducing the anxiety associated with speaking, starting by removing pressure to speak. The person then progresses gradually from relaxing in the school, nursery or social setting, to saying single words and sentences to one person, before speaking freely to all people in all settings.

The Royal College of Speech and Language Therapists advises parents not to pressurise or bribe a child to speak, to let them know you understand they are scared, to reassure them that non-verbal communication such as smiling and waving is fine until they feel better, and not to praise them publicly for speaking, which can cause embarrassment. It suggests asking friends and relatives to give the child time to warm up at their own pace and focusing on fun activities rather than getting them to talk.

The NHS adds that individual treatment can sometimes be avoided if family and early years staff work together to reduce anxiety: not letting the child know you are anxious, reassuring them that they will be able to speak when ready, praising all efforts to join in, and not showing surprise when the child speaks. Medicine is only appropriate for older children, teenagers and adults whose anxiety has led to depression, and should never replace environmental change and behavioural therapy.

The NHS says selective mutism can continue into adulthood if it is not managed, and that a child or adult with the condition is literally unable to speak in certain settings. Adults may spend years avoiding situations such as phone calls, interviews or college life, and the NHS notes that adults may lack qualifications because they are unable to take part in college life or interviews.

It is possible for adults to overcome it, although the NHS says they may continue to feel the psychological and practical effects of years without social interaction or of not reaching their academic or work potential. Adults will ideally be seen by a mental health professional with access to support from a speech and language therapist or another knowledgeable professional.

The NHS says some health professionals use medicine alongside a treatment programme in adults to lower anxiety, particularly if earlier attempts to engage the person in treatment have failed. It stresses that medicine should never be offered instead of environmental changes and behavioural approaches.

The NHS advises not to accept the opinion that your child will grow out of it or is "just shy". If you suspect selective mutism and help is not available, or there are other concerns (for example the child struggles to understand instructions or follow routines), it suggests speaking to a GP and asking for a referral to a local specialist service for a formal diagnosis. You can also contact a speech and language therapy clinic directly.

A sudden change is different. The NHS says that when mutism occurs as a symptom of post-traumatic stress it follows a very different pattern, with a child suddenly stopping talking in places where they previously had no difficulty. A sudden loss of speech in a child who had been talking freely should be discussed with a GP promptly.

The NHS says your GP or local integrated care board (ICB) should be able to give you the telephone number of your nearest NHS speech and language therapy service or another specialist service that can help. Your child may also need to see a mental health professional or school educational psychologist, and staff in early years settings and schools may receive training so that they can support children with selective mutism.

The NHS also says the Royal College of Speech and Language Therapists and the Association of Speech and Language Therapists in Independent Practice can help you find professionals with experience of treating selective mutism. The Royal College cautions that professionals in an area may not have up-to-date knowledge or experience, in which case it suggests seeking teachers and healthcare professionals who are willing to listen and learn.

Whichever route you use, ask how the school will be involved. The NHS says the effectiveness of treatment depends on the co-operation of everyone involved with the person's education and family life.