Selective Mutism: Care Staff Guide to Anxiety and Communication

Selective mutism is an anxiety disorder in which a person is unable to speak in certain social situations, even though they can speak comfortably in others. It is often mistaken for shyness, stubbornness or rudeness, and that misunderstanding can make things worse. This guide, based on NHS information, explains what selective mutism is, what helps and what does not, and how care and support staff, teachers and carers can respond. It links to our guides on generalised anxiety and panic disorder, Oliver McGowan mandatory training and stammering.

What is selective mutism?

The NHS describes selective mutism as an anxiety disorder that causes an inability to speak in certain social settings. It often involves classmates, teachers or relatives who are rarely seen. It usually starts in childhood and can continue into adulthood if untreated. The NHS stresses that it is not a choice: speech is physically blocked by a freeze response. The person can usually speak with close family or friends. The NHS says about 1 in 140 young children are affected, and it is more common in girls and in recent migrants.

Signs

According to the NHS, signs usually begin between the ages of 2 and 4 and are often first noticed at nursery or school. They include:

• sudden stillness and a frozen expression in situations where speech is expected
• avoiding eye contact, and seeming shy, clingy, sulky or tense
• temper tantrums at home after school
• using nods or head shakes, or in severe cases avoiding all communication
• whispering or speaking in an altered voice

Causes

The NHS explains that selective mutism is viewed as a phobia of speaking to specific people. It is linked to anxiety, and many children had a tendency to anxiety beforehand. Separation distress, speech or hearing problems, or sensory processing difficulties may contribute. Post-traumatic stress can cause mutism but with a different pattern. It is not the same as autism, although the two can occur together.

Diagnosis

For children, the NHS says early identification by families and schools helps. A GP can refer to a specialist service. Clinicians may talk to parents on their own first, and alternative ways of communicating, such as writing, speaking through parents or video, may be used. Adults are assessed by a mental health professional, ideally with speech and language therapy input. The NHS says the criteria include silence in specific situations, normal speech in comfortable ones, lasting at least one month (two months in new settings), affecting daily functioning, and not being better explained by another condition. It also says that "just shy" should not be accepted as an explanation.

Associated difficulties

The NHS notes other fears and social anxieties, avoiding food and drink to avoid asking to leave the room (which can lead to urinary infections), problems with classwork and homework, limited independence in the teen years, and lower qualifications or job prospects in adults.

Treatment

The NHS says most children improve and that earlier diagnosis means quicker progress. Treatment focuses on reducing anxiety and not on forcing speech. It includes removing pressure, staying calm and praising efforts privately. Therapies include cognitive behavioural therapy and behavioural therapy, using techniques such as graded exposure, stimulus fading, shaping, reinforcement and desensitisation. Medicines, such as antidepressants, are mainly for older children and adults and are used alongside therapy, never as a replacement.

How staff, teachers and carers can help

The NHS gives clear advice:

• avoid pressure and bribes, and do not show your own anxiety
• reassure the person that they can speak when they are ready
• accept nods, smiles and gestures
• respond warmly and without surprise when the person does speak
• praise efforts privately rather than in public
• give relatives and friends time to let the person warm up
• keep activities fun and low-pressure
• keep attending parties and family visits, adjusting settings as needed

Staff supporting adults can apply the same principles. Offer alternative ways to communicate, such as writing, pictures or messaging, and never insist that the person speaks in front of others.

Outlook

The NHS says most children overcome selective mutism with appropriate support, and adults can improve too, though lasting effects from years of isolation may remain. Untreated, it can lead to isolation, low self-esteem and social anxiety disorder.

When to get help

The NHS advises asking a GP for a referral to a local specialist or speech and language therapy service if you suspect selective mutism, or if there are further concerns such as trouble following instructions. You can also contact a speech and language therapy clinic directly. If a person is in crisis, call NHS 111 or, in an emergency, 999.

Frequently asked questions

Is selective mutism just shyness?

No. The NHS says it is an anxiety disorder in which speech is blocked by a freeze response.

Is it the same as autism?

No, though the NHS notes that the two can occur together.

Should we encourage the person to speak?

Not by pressure. The NHS advises removing pressure and accepting other forms of communication while therapy reduces anxiety.

Where can staff build their knowledge?

The health and social care learning available through Learnsignal CPD can help you support people with anxiety and communication needs.

This article is general information for care staff, based on NHS information, and does not replace the advice of a person's own clinicians. If you are worried about someone's health right now, contact their GP, NHS 111 or, in an emergency, call 999.