Help Me To Speak

Programme 2, Monday 10 April 9pm on Channel 4

Nine-year-old Robert and five-year-old Madeleine have a rare condition called selective mutism. It's a anxiety disorder which prevents the children speaking in social situations. Both children are normally very talkative at home with their parents and siblings. However, as soon as they step out of the door they become silent.

© channel 4

The consequences of failing to overcome their self-imposed silence could range from basic difficulties in learning at school, in the short term, to getting a job in later life. There is also the risk to their emotional and social well-being – if they refuse to talk, how can Robert and Madeleine even make friends? The programme follows the children as they embark on different courses of treatment – will they be able to overcome their fears and start to speak again?

To find out more about selective mutism and the support available for parents of children with this condition and other communication difficulties, see our feature below or visit help and info for relevant organisations, website and books.

seen but not heard

by Jo Carlowe

seen but not heard | help and info

Imagine the frustration of having a child who is a lively, chatterbox at home but utterly silent at school. This condition, a rare anxiety disorder, is called 'selective mutism' (SM), and although few people have heard of it, some experts say six to eight children in every thousand may be affected.

© iStockphoto.com/
Bonnie Schupp

Children with the disorder are fully capable of speech but fail to talk in certain social conditions. You could think of it as an extreme form of shyness but the intensity and duration of the problem distinguishes it.

SM children have an actual fear of speaking and of social interactions where there is an expectation to talk, even though logically there is nothing to fear.

It is much the same as other phobias – the anxiety over talking triggers a panic response causing the heart to race, the palms to sweat and the body to tense-up.

Lindsay Whittington, honorary secretary of the Selective Mutism Information and Research Association (SMIRA) says such an anxiety attack actually renders the child unable to speak. 'It's almost like a paralysis of the throat and by the time the child has reached the age of eight or nine, it has become a habit that is difficult to break.'

Ms Whittington's own daughter suffered from SM in childhood but has since recovered. 'For parents, it is like living with two children rolled into one. At home they are lively, boisterous and intelligent but at school the teachers say they have never heard them speak even after two terms.'

what causes selective mutism?

The exact cause of SM is unknown although most experts believe SM children have a genetic predisposition to anxiety.

Educational psychologist, Professor Tony Cline, of University College London, says there is little 'convincing' research on the precise mechanisms for SM and genetics but the anecdotal evidence is quite compelling.

'There are good reasons for believing that there is a genetic component in children's susceptibility to develop a pattern of selectively mute behaviour: Parents have themselves had a history of this rare pattern of behaviour more often than you would expect by chance; parents or family members have a higher than average incidence of social phobia and shyness; and the same applies to siblings. With rapid progress being made in the genetics of behavioural development, we can anticipate that this will be explored in the next decade or so.'

seeking help

The fact that there is relatively little research into SM is telling – it highlights limited awareness amongst health professionals.

'When parents ask GPs for advice, the majority are told their children will grow out of it. Some children do but most need help. Often it is up to the parent to educate themselves,' explains Mrs Whittington.

SMIRA is a good first port-of-call because it produces an information pack. Usually parents who have contacted SMIRA do so because their child isn't speaking at school. The average age of diagnosis is between three and eight years old, although in retrospect many parents will say that their child has displayed signs of excessive shyness since infancy. It is only when the child reaches school – where there is an expectation on them to speak – that the selective mutism becomes more apparent.

How schools deal with the problem is varied. 'I get teachers saying they have taught for 30 years and have never come across the condition, while others say they have three children who suffer from it,' says Mrs Whittington.

If the mutism has continued for more than a month then parents should seek help. Schools are often the gateway through which to get this – usually via educational psychologists and speech therapists.

types of treatment

As Selective Mutism is an anxiety disorder (a study by psychologists at Hofstra University in New York revealed that 97 per cent of SM children suffer from excessive social anxiety) successful treatment focuses on methods to lower anxiety and increase confidence in social settings.

Initially, parents are told to take the pressure off the child by accepting that they do not speak in certain situations.

Treatment often takes the form of behavioural therapy, which uses desensitisation to expose the child to their fears in a gradual and controlled way.

Sometimes cognitive behavioural therapy (CBT) is used – the behavioural part helps the child to change their actions, and the cognitive part helps them to change their thoughts. CBT therapists recognize that anxious children tend to exaggerate the frightening aspects of certain situations, so they help them to gain a more realistic perspective in order to decrease anxiety.

A behavioural technique commonly used to treat SM is 'stimulus fading'. This starts with a situation that is comfortable for the child, such as being alone in the classroom with a parent and playing a board game. Progressively more difficult variables are then added such as having the teacher walk past the room and overhear the child speaking to the parent, and then having the teacher enter the room.

Some therapists use video or audio taping to desensitize a child to the sound of his/her own voice. Recordings may be spliced together to make it appear that the child is speaking to another person. This method, called 'self-modelling', is based on the concept that 'seeing is believing'. It is only used if the child understands and consents to its use. The American Academy of Child and Adolescent Psychiatry has reported some success with this technique.

Another line of treatment is drug therapy. Anxiety problems relate to an imbalance of the chemical 'messengers' in the brain (called neurotransmitters). Drugs such as Prozac are used to correct the imbalance.

Although medication is commonly used in America, it tends to be the treatment of last resort for British children.

'Behavioural strategies are less invasive,' explains Professor Cline. However, he accepts that there 'is some evidence of success' when medication is used on its own, and more particularly, when it's used in conjunction with behavioural techniques.

what's the long-term outlook for SM children?

Left untreated, SM children may develop more entrenched problems in adolescence and adulthood, including depression and social isolation.

'Without help, it is sink or swim,' says Mrs Whittington. 'Some of these children grow into very introverted adults and become unemployable.'

Clearly such an outcome is tragic, when good intervention is known to work.

Professor Cline says although there has been little research into the long-term prognosis of child sufferers who are not given help, appropriate treatment can yield positive results.

'There are many reports in the literature of SM children presenting as indistinguishable from others in later childhood and in subsequent adult development.'

(April 2006)

Read on for details of relevant organisations, websites and reading.