QUESTION
My daughter is almost five years old and has gone through a year of playschool without speaking a word to the teacher or children there. She speaks freely at home but does not speak to extended family or anyone else. But she will speak to me, my husband and her brothers anywhere.
She is seeing a psychologist and has not been accepted into the Child and Adolescent Mental Health Services. She has been diagnosed with selective mutism. I have a few books on it – Maggie Johnson’s manual – and picture books for her. I have looked at SMIRA (the Selective Mutism Information and Research Association). Do you know of any good resources or advice on this?

I am aware of the difficulties that can arise if no progress is made. Already there are difficulties for her as friendships have been formed and she is isolated as a result of mutism.

ANSWER
While lots of children are quiet or shy, selective mutism is a more serious problem when a child does not speak at all in certain social situations. A child with selective mutism might be chatty at home with their parents and other family members, but completely silent outside the home or at school.

Selective mutism is best understood as an extreme form of social anxiety. Rather than choosing not to speak, the child might become frozen with anxiety in a class or they might develop a phobia of speaking in public. Once selective mutism becomes a habit, it can be harder for the child to break it and can lead to long-term problems such as being disengaged in school and missing out on social opportunities.

Getting help for a child with selective mutism It sounds like you have already done a lot to get help for your daughter by getting her assessed by a psychologist, making contact with SMIRA (the Selective Mutism Information and Research Association) and consulting the work of Maggie Johnson, a leading clinician in the area who has co-written the Selective Mutism Resource Manual, one of the most widely used treatment approaches.

Usually, the best treatments are multi-disciplinary and are led by a speech and language therapist or psychologist. I am surprised your daughter has not been accepted for treatment at your local Child and Adolescent Mental Health Service (CAMHS) who should offer this multi-disciplinary service and should accept a referral for selective mutism.

An alternative is to access a speech and language therapist via your local HSE Primary Care Centre or discuss with the psychologist you are in contact with about options. Contact your local disability manager at the HSE if you have trouble getting a service.

What helps children with selective mutism
The most important thing you can do is be very understanding and patient with your daughter. When you have a child with selective mutism it is easy to get frustrated with them when they don’t speak – because you know they can – and to end up constantly asking or pressurising them to speak. However, this can be counterproductive.

As your child can’t speak due to anxiety, pressurising them or drawing attention to the fact they are not speaking will only increase their anxiety and self-consciousness and even make them feel bad for having the problem. As a result, it is important to be relaxed, patient and encouraging.

You can acknowledge with your daughter in advance that “talking can feel scary sometimes”, and then be reassuring “don’t worry, once you start it feels easier and you are being brave trying”. 

If possible, educate people in advance of meeting your daughter so they don’t make a fuss of her not speaking. Model good conversation yourself and include your daughter normally as you might with any child her age without drawing too much attention to her.

Certainly, don’t make a big deal if she does communicate a little more as this will put her off and increase her anxiety. Instead, just repeat what she has said and ask her a further question.

Use a gradual approach to help your daughter speak
As with many phobias and anxiety problems, a step-by-step gradual approach usually works best in overcoming them. Rather than leaping ahead and tackling all of the problems at once, the goal is to break them down into small steps and tackle the smallest step first. For example, if it is hard for your daughter to speak in public to strangers, then maybe you could start with her learning to speak to you when strangers are nearby.

The key is to come up with a clear step-by-step programme for your child to work on and often this is best developed in consultation with a clinician such as a speech and language therapist (SLT) who has assessed the specifics of your daughter’s situation.

In trying to increase your daughter’s speaking at school, the SLT might put together a programme that consists of her spending 10 minutes daily with a resource teacher or learning support teacher at school. They would work through a detailed programme that starts with the smallest steps of speaking one-to-one in an empty room and builds towards your daughter speaking in the classroom.

For example, in the beginning, the programme might consist of some of the elements below:
1. Communicating non-verbally with your daughter, perhaps via an imitation game to put her at ease.
2. Focusing on making and mimicking animal noises as a means to getting your daughter to make sounds.
3. Inviting your daughter to make vocal sounds using a toy such as a Kazoo to get her used to someone else hearing her voice in school.
4. Inviting some simple one-word communications between your daughter and the teacher, and progressing to sentences and conversation.
5. Gradually introducing other children to the room, so your daughter learns to speak in their company.

You are right to seek intervention for your daughter so do follow up with the services listed above. In addition, there are lots of good resources online with detailed information on how you can help your daughter such as the SMIRA Facebook page and selectivemutism.org. There is also a good Channel 4 documentary on Youtube if you search ‘Help me to speak’.

John Sharry, Irish Times Newspaper, September 2016. John writes in the Irish Times Health+ every Tuesday.
For information on John’s courses for parents visit www.solutiontalk.ie