Spotlight on selective mutism following trauma

Selective mutism is a complex disorder which can be related to trauma, social anxiety and can be classed as a phobia. It presents when children are in environments where they are sensitive to being observed or pressured, such as in school or social situations. Despite their ability to speak freely in specific situations or surroundings, these children may struggle in other settings where the expectation to talk provokes panic and profoundly impacts their ability to interact. Recognising this as a communication and language barrier rather than a defiant behaviour is central to fostering a supportive environment.

Clare Vaughan is a Bush & Co expert witness with a current caseload which includes a young woman in her early 20s, whom Clare began supporting at 16. Initially, this client communicated only at home and left school early without taking her GCSEs due to a lack of support at school. She is a keen horse rider and has made progress and now speaks with her mother at the stables in private areas. However, despite attending college to study for her British Horse Society qualifications, she still struggles to communicate verbally with her tutor, whom she has seen once a week for three years. Clare's ongoing support aims to build confidence and facilitate communication in familiar and educational contexts.

Clare is also supporting a client with autism who began exhibiting selective mutism at six, believed to have been triggered by a comment made by a teacher. Currently, he only speaks at home; however, he is a talented artist who can interact with strangers he sees as he is unaware of his condition. Clare's work with this client focuses on building confidence to facilitate communication in various contexts and strengthen skills in other areas, such as problem-solving.

Understanding selective mutism

The fifth issue of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (APA) in 2013, characterises selective mutism as an anxiety disorder where individuals find themselves unable to speak in certain situations despite being able to communicate comfortably with others.

The International Classification of Diseases (ICD11), produced by the World Health Organisation and adopted in the UK, extended this definition in 2018 to describe selective mutism as an anxiety or fear-related disorder and represents the consensus on how the condition is described.

Characterisation and Diagnosis

Selective mutism is typified by a consistent inability to speak in specific social environments and should be differentiated from general shyness or refusal to speak. A comprehensive assessment by a mental health professional is vital for accurate diagnosis, incorporating in-person observation of communication patterns and ruling out any speech or language disorders.

Prevalence and Onset

This condition is relatively rare, affecting less than 1% of children, and often becomes apparent when children start school and are expected to engage in more complex social settings. The typical age of onset for selective mutism is between three and six years old, coinciding with critical stages of children’s social development.

Early identification is crucial in addressing potential complications in academic and social performance, and understanding the prevalence helps teachers and parents recognise the signs and seek interventions quickly. Children with selective mutism are often mistakenly seen as merely shy, highlighting the need for greater awareness of this condition.

Selective mutism and trauma

While the root causes of selective mutism are unknown, there is a significant correlation between trauma and selective mutism, as traumatic experiences can profoundly impact a child's emotional and psychological development. Children who have encountered distressing events may develop heightened levels of anxiety and fear, leading them to withdraw from verbal communication as a coping mechanism.

This selective silence is a protective barrier against perceived threats in social interactions. Understanding the relationship between trauma and selective mutism is crucial for developing effective therapeutic interventions, as addressing underlying trauma can facilitate the gradual reintegration of speech in various social contexts.

Assessment and care

There are multiple approaches to managing selective mutism, including therapeutic strategies and behavioural interventions. Informed support from parents, educators, and peers is important to encourage progress, with resources including the Selective Mutism Information & Research Association offering additional guidance for those looking to support individuals affected.

Behavioural Therapies

Behavioural therapies, such as Cognitive Behavioural Therapy (CBT), are commonly used and focus on helping individuals gradually overcome their speaking fears. For example, systematic desensitisation, where the individual is slowly exposed to speaking situations, can be an effective technique. Alternative approaches include positive reinforcement, which encourages verbal attempts by motivating children to communicate more frequently using rewards. However, given the challenges in speaking associated with selective mutism, talking therapies can sometimes not represent the best approach.

Supportive Strategies in Education

Educational settings play a key role in supporting children with selective mutism, and teachers can work with mental health professionals to develop tailored education plans that accommodate the child's specific needs. The use of visual aids and non-verbal communication methods can also help children express themselves without pressure.

Small group interactions can help ease speaking anxiety, providing opportunities to build confidence gradually. Teachers should be trained to recognise signs of anxiety and implement classroom management techniques that minimise stress. Involving parents through regular communication ensures that strategies are consistent across settings and helps reinforce the child’s progress.

Clare Vaughan, Expert Witness and Speech and Language Therapist at Bush & Co., highlights the challenges in assessing selective mutism:

Assessing selective mutism presents a unique set of challenges, particularly due to the absence of standardised tests designed for this condition. The non-communicative nature of individuals affected by the disorder further complicates the process, as traditional evaluation methods often rely on verbal interaction. Practitioners must therefore adopt a nuanced approach, utilising observational techniques and engaging with the child's environment to gain insights into their communication abilities and the underlying anxieties that contribute to their mutism.

Psychiatric intervention can prove challenging with non-speaking clients, so active family involvement is crucial for successful treatment. Engaging parents and siblings in therapy sessions helps promote a supportive home environment, and establishing a consistent routine may lessen anxiety triggers.

Communication strategies focus on gradual exposure to anxiety-inducing situations. Techniques like sliding-in – where new people and language activities are introduced to therapy gradually – can be beneficial. Another technique is modelling - where a child observes peers speaking in similar contexts. Social skills development involving role-playing exercises helps children practice conversations and improve self-expression in social contexts. Each person with selective mutism presents slightly different communication challenges and has different responses to therapies, so it is important they are tailored to individuals to ensure they are effective.

Incorporating technology, such as voice-recording apps, can offer children a less intimidating means of communication. Gradually, these strategies contribute to a child's confidence in speaking in various social scenarios.

Expert Witness Support

Bush & Co. offers expert witness report services that leverage the expertise of experienced speech and language expert witnesses in cases involving clients with selective mutism. Our trained professionals conduct in-person assessments that provide a qualitative evaluation of cognitive abilities, using evidence-based tools to inform clinical decisions.

These assessments include recommendations for any enhanced communication technologies aimed at supporting the rehabilitation and increased independence of clients. This comprehensive approach ensures the unique needs of each client are met, helping effective communication and enhancing their overall quality of life.

Clare Vaughan - Expert Witness and Speech and Language Therapist at Bush & Co

Clare Vaughan is a highly experienced Speech and Language Therapist (SALT) specialising in assessing and treating children and young people aged 5-21 with various speech and communication difficulties, including those with additional needs such as autism, cerebral palsy, ADHD, and learning difficulties. Clare has extensive experience in assessments, diagnoses, and developing care pathways and is also qualified to conduct diagnostic dyslexia assessments, holding an APC certificate with PATOSS.

Her professional background includes significant work in mainstream schools and colleges, where she has observed and assessed students, collaborated with SEN staff and educational psychologists, and trained others on speech and language strategies. Clare manages a diverse caseload that includes children with brain injuries, cerebral palsy, and those affected by complex trauma. She is adept in addressing behavioural, social, and psychological aspects of communication difficulties, including selective mutism and anxiety disorders, and is knowledgeable in alternative augmentative communication methods.

Clare is an expert witness specialising in quantum and liability assessments, working with both Claimant and Defendant Solicitors. Since joining Bush & Co, she has completed over 100 instructions related to causation and quantum, demonstrating her expertise in report writing and collaboration with Counsel. Additionally, Clare provides expert speech and language therapy (SALT) opinions for families in educational tribunal cases and frequently attends tribunal hearings.

Clare's qualifications include a BSc (Hons) in Speech and Language Pathology, a Post Graduate Certificate in Specific Learning Difficulties (Dyslexia), and a Certificate in Education. She is a member of the Royal College of Speech & Language Therapists and the Health and Care Professions Council.