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This document was co-authored by a parent and Maggie Johnson (UK, NHS) and includes numerous references to research materials related to the specific topic covered by the document.
The parent is just a dad, father of three multi-linguals, the eldest of which was diagnosed with SM aged 5. Following intervention based on literature originally authored by Maggie Johnson and Alison Wintgens (Selective Mutism Resource Manual, 2001) his daughter was speaking in school 18 months later.
Since then, Dad continues to monitor her progress, and this document is one result of her experience.
This document is published by SMIRA and is written by a dedicated parent, known to SMIRA, from their own experiences, in the hope that it will be useful to others.
Disclaimer: The opinions expressed here are not necessarily the views of SMIRA.
Multi-lingualism and SM
This is a favourite subject of mine, simply because my daughter MissT is tri-lingual, and used to have SM. She migrated from one European country to a neighbouring European country aged 3. Both countries are at least bi-lingual. For this reason, I will discuss migration as an issue in this document, as migration sometimes incurs a new language.
In the Carmody Factors* list, two factors are mentioned in the list of 3Ps
• Frequent moves or migration
• Family belonging to an ethnic or linguistic minority
The Silent Period
For anybody learning a second or even third language, it takes time, time to acquire the vocabulary (words) and time to hear the accent. The research has shown that many children have a so-called ‘silent period’, while they try to acquire a new language. This is a very different concept to what we know as SM.
The younger the child, the longer the silent period tends to last. Older children may remain in the silent period for a few weeks or a few months, whereas pre-schoolers may be relatively silent for a year or more. However, a silent period of several months is by no means inevitable nor even typical in second language learning.
There is probably no set timescale for learning a language. Everybody learns at different speeds. Some young children will be fluent in class with their peers in 6 months. It would be dangerous to let 6 months of silence go by and then expect children to suddenly start speaking. But as parents of children with SM will know, bombarding a child with questions as recommended by Priscilla Clarke (1992) is not the answer either! See:
The diagnostic criteria for SM are globally the same. Defined by the United Nations UNWHO F.94 or DSM5 (previously DSM-IV-TR). Nursery staff, teachers is pre-school or primary, or Secondary depending on the age of a child will see an anxious child undergoing a culture shock as they try to assimilate culture and language in a new environment. Yes, a new space!
Recently Maggie Johnson has told me that she advises of “potential SM during the silent period in a second language learner’s new school environment”. This does not mean a longer period (e.g. 6 months) before diagnosing a child with SM, where the child is living in a world using their second language. This silent period is “a time of language learning and inner language rehearsal when, for whatever reason, the child is not ready to speak outwardly, but is processing the language inwardly. Their understanding may be no more delayed than their speaking counterparts.” As we know with SM, the simple ‘failure to speak’ will hit a child very hard if they are trying to learn a second language. Maggie’s advice goes on to say “If a bi/multi-lingual child was showing signs of anxiety in the ‘silent period’, with other signs of selectivity (e.g. limited non-verbal communication in school setting) and was capable of using the new language in some settings (e.g. playing with new school friends at their home) I’d definitely be making a diagnosis of SM before the child emerged from the silent period, rather than waiting six months.”
Maggie Johnson has also given me access to research from Israel which shows statistics giving a higher than normal rate of SM for immigrant children 2.2% instead of 0.76%. (See below Elizur & Perednik, 2003). Anxiety tends to rise when you migrate as is noted in the Carmody list.
SM is a global phenomenon. It is identified by the World Health Organisation (WHO) which deals with most of the world’s population via the United Nations. The majority of cases of SM will not be bi-lingual.
Some countries are legally bi-, tri-, or even quadri-lingual. Think about Belgium, Luxembourg, Switzerland, India, China, Singapore etc. These countries do however have education systems which recognise other languages in a much better way than a mono-lingual country. At the same time, migration is and has always been a global issue. Peoples have always moved around. It’s a natural process. The idea to cross international frontiers is artificial, but it is a fact of life which sometimes causes harm. I can think of so many cases where international borders are causes of dispute, which in turn ‘force’ families to migrate. It’s nothing new.
Cultural boundaries exist as well. A foreigner will always be different, until that is another group migrates into the foreigner’s area, and they themselves become the locals. Think ‘Irish in New York’ …
Differences always cause friction. Friction can appear as violence, bullying, or even teasing in the negative sense. Some cultures accept difference positively, others don’t.
Support Approach for SM
Treatment, therapy and awareness all have a role to play.
SMIRA always advises ‘sliding-in’ for treating SM, either an informal approach or a formal sliding in programme with small steps targets.
A new child in class? Make them at ease by helping children settle into new environment without feeling pressured to speak before they’re ready giving time to slowly acclimatise to their new environment. Informal sliding-in using parents and peers is absolutely fine however (no specific target sheets, just respecting child’s space and only gradually getting closer as they talk to and play with parents/peers). Sometimes it will take longer than you planned. With SM, even longer, and by putting pressure on them, even longer still.
Personally, I think this ‘informal’ sliding can be used almost anywhere where there is anxiety. I’ve been sliding MissT in and out of places for years, and I personally slide in and out of her space whenever I see the need. I’m managing her space from the outside.
There are various other factors on the Carmody list which can be made worse by relocation. Some host communities find it difficult to accept foreigner into their community and the usual social barriers go up. Call it xenophobia or whatever it maybe.
Advice for bi-lingual families of families learning languages
There are various combinations of family and language, but let’s look at just two:
- A monolingual family arriving in a new country and having to learn a new language
- A bi-lingual family where parents speak different native languages and their children are exposed to both languages at home.
a. The child is exposed to one of those languages at school
b. The child is exposed to a third language at school
I have three children. They are all at least bi-lingual. My own personal advice starts with a principle:
Parents should speak their own native language to their child.
This principle is based on the idea that a young child/infant will associate a parent with a language from the start. The ‘mother-tongue’ means just that, but we never speak of the ‘father-tongue’ which should have equal weight, in my opinion. I’m just a dad, and my MissT is fiercely proud of her British roots, less so for her place of birth, and even less so for her maternal grandfather’s place of birth.
I think this is more to do with a negative role model, than the country or the region.
My MissT has grown up in a tri-lingual world. Occasionally she would get cross with us as we gabbled on in all three languages at the same time. She would occasionally intervene between her parents telling one of us what was said in one language and translating it to the other in another language. It’s an amazing facility to have.
Research has shown that a small proportion of children with innate language difficulties (i.e. difficulty learning even their native language) will get confused if two or more languages are interwoven or used in the same conversation – they need to keep the languages separate but can learn both. Anxious children just need consistency. They can understand that sometimes Mum/Dad needs to speak a different language to people who don’t speak their native language, and that it’s polite to swap their own language too, just while that person is present. As soon as teacher leaves the room for example, they can go back to talking native language with the parent.
Anthea Fraser Gupta, Senior Lecturer at the School of English, University of Leeds says:
Children are not confused by hearing more than one language. We have known for a long time that bilingual children separate their language from the age of 2: current research suggests they separate them from the beginning.
People who grow up in bilingual communities like Singapore take bilingualism for granted. Parents typically speak two or three languages to children, and parents and children often mix languages in the same sentence. Mixing languages in the same sentence doesn’t confuse children. And if the child mixes languages it is not a sign of confusion. The children learn the complex rules for when to use which language (and when you can use a mixture). They start to demonstrate that they know these rules before they are 2 years old. By the age of 2 we can clearly see that bilingual children faced with a monolingual adult will do their very best to speak in the language the monolingual knows. But remember that a child will not have learnt the same words in both languages: if a child doesn’t know a word in a language they want to speak, they may use a word from another language that means the same (many of us use the same technique as adults!): this is nothing to worry about. Indeed, it shows that the child
knows how to translate. Don’t worry about the child mixing, even if you never mix. You can expect it.
The ‘one-parent-one-language’ method is sometimes put forward as the only way to raise bilingual children. It isn’t. There are many routes to this end. If both parents can speak a minority language then their best strategy might be to speak only the minority language to their children, and let them learn the majority language of the community outside the home. If the family lives in a place where everyone is bilingual in the same two languages, then they should behave naturally, switching languages and mixing them as they normally do.
I have met many individuals who tell me that their parents chose their language for them. Migrant families sometimes choose to assimilate completely into the local environment, and therefore avoid their own native tongue. They make a choice:
- The whole family choses one language (either the language of the environment or the preferred native language at home);
- Each parent choses their native tongue and remain with that until the child is comfortable with that.
- Parents choose one language at home, a second language at school, and speak in a third language when they discuss an issue with the child, while the child is present, thinking that the child won’t understand that ‘extra’ language.
MissT has 3 languages based on her grandparents. She delayed her third language herself, remaining mute until recently. She has since this academic year started classes in the third language but is already naturally fluent as a result of full-emersion with her cousins since birth. Lucky her! She recently scored a 10 in her third language exam, so despite her not using the language for 12 years she had acquired it. For her I believe that third language had some associations which she didn’t like, but she has now seen the benefits of using it in other spaces. Good for her!
Would you migrate?
People and families make choices. They move. They relocate. They emigrate, immigrate, migrate. All of this can add anxiety.
I moved my family and I will move again.
I have heard families move, and then return ‘home’ as a result of SM in the new environment. It’s an option, a choice to make.
Others decide to stay and try to overcome SM, as I did.
A personal message
Personally, I find being bilingual is an advantage for any child in the world we live in. I would always encourage cultural diversity in a family and within the environment where they chose to live. Assimilation doesn’t mean total conversion to the ‘local’ system. The system has to have some flexibility too.
As a European, I have the right to live and work anywhere in Europe. When I chose to leave the UK, they called it the brain-drain … it was a positive for me. I’ve lived more of my life ‘abroad’ than ‘at home’. I pay taxes and I’ve claimed money from social services, including child benefit. I’ve been accepted by most, treated as a foreigner by few. Every day is an adventure.
I must at this point say a massive thank you to Maggie Johnson who has guided me in this version of the document. Her work will continue to guide me, just as her SMRM book, co-authored by her and Alison Wintgens guided me when I first heard of SM.
I hope this helps … I find this subject a pure fascination, and I hope this new version of the document is taken for what it is … I’m just a dad, guided, yes, I read around the subject … I’m no scientist, specialist, researcher … just a dad. Now read this document again with that in mind …
The following is provided for reference purposes for those interested.
(The following information is kindly provided by Maggie Johnson)
Highlights from the following extracts:
“The general prevalence of SM was 0.76%, while the rate among immigrants was 2.2%.”
“Diagnosed in 1/141 children”
Abstract below from
Manassis K. – Silent suffering: understanding and treating children with selective mutism. Expert Review Neurotherapeutics. Feb 2009;9(2):235-43
Children with selective mutism (SM) restrict speech in some social environments, often resulting in substantial academic and social impairment. Although SM is considered rare, one or more children with SM can be found in most elementary schools. Assessment is performed to confirm the diagnosis, rule out psychological and medical factors that may account for the mutism, ascertain comorbid and exacerbating conditions needing treatment, and develop an intervention plan. Interventions are often multidisciplinary and focus on decreasing anxiety, increasing social speech and ameliorating SM-related impairment. Research is limited, but symptomatic improvement has been demonstrated with behavioral interventions and multimodal treatments that include school and family participation, as well as behavioral methods. Selective serotonin-reuptake inhibitors, especially fluoxetine, have also been found to be efficacious and merit consideration in severe cases.
Persistence of some SM or anxiety symptoms despite treatment is common. Further development of treatments targeting specific etiological factors, comparative treatment studies and determination of optimal involvement of families and schools in treatment are needed to improve outcomes for children with SM.
From Bergman 2008
Prevalence and Diagnosis
Based on few published studies with discrepant results, SM has previously been thought of as a rare disorder. Recent research has focused on the school setting to determine the prevalence rate of SM. Using standard diagnostic criteria, one U.S. community prevalence study surveyed kindergarten, first, and second grade teachers in an urban public school district and found a .71 percent prevalence rate for SM (Bergman, Piacentini & McCracken, 2002). Another study conducted in Israel found a similar rate of .76 percent in the community (Elizur & Perednik, 2003). These most recent and consistent findings suggest that SM may be more common than generally believed, with a prevalence rate similar to or greater than rates of other more publicized and commonly known childhood psychiatric disorders, including obsessive-compulsive disorder, major depression, and autism.
Elizur Y, Perednik R (2003) Prevalence and Description of Selective Mutism in Immigrant and Native Families: A Controlled Study. Journal of the American Academy of Child and Adolescent Psychiatry, 42 (12): 1451-9.
From Camposano, L. (2011). Silent suffering: Children with selective mutism. The Professional Counselor: Research and Practice, Vol.1, Issue 1,pages 46-56. http://tpcjournal.nbcc.org
Recent studies suggest that selective mutism may occur in .7 to 2% of early elementary students, although many researchers agree that these prevalence rates may be underrepresented due to the lack of knowledge of the disorder
(Cunningham, McHolm, & Boyle, 2006; Lescano, 2008; Schwartz et al., 2006; Sharkey, McNicholas, Barry, Begley, & Ahern, 2007).
European Child & Adolescent Psychiatry .1998 Mar;7(1):24-29. Volume 7, Number 1, 24-29, DOI: 10.1007/s007870050041
Selective mutism among second-graders in elementary school
K. Kumpulainen, E. Räsänen, H. Raaska and V. Somppi
This study assessed the prevalence of selective mutism among second graders in elementary school, and examined related issues such as the situations in which the children refuse to speak, their performance level at school, and some temperamental/behavioural characteristics of these children.
A definition of selective mutism (according to the DSM- III-R) was sent to all second grade teachers in the study area, asking them if there were any children with these symptoms in their class. If a positive answer, the teacher was asked to fill in a questionnaire concerning the child.
The prevalence rate for selective mutism was found to be 2%, with girls outnumbering boys. Selective mutism had been in progress more than a year in most cases. Most often, the children refused to speak to the teacher (58%), and one-fifth spoke to nobody at school. One-third of the mute children were performing at a lower level than average. Fewer of these children were reluctant to speak to the teacher than were mute children with an average or higher than average performance level. The children were characterized as shy, withdrawn and serious, with only some being hyperactive or aggressive. About one third of the children had had contact with health services.
Bergman, L.R., Piacentini, J., & McKracken, J.T. (2002). Prevalence and description of selective mutism in a school-based sample. Journal of the American Academy of Child Psychology, 41, 938934.
Diagnosed in 1/141 children (16 of 2256 in the study)
Journal of the American Academy of Child & Adolescent Psychiatry, Volume 41, Issue 8, August 2002, Pages 938–946
Prevalence and Description of Selective Mutism in a School-Based Sample (Los Angeles)
· R. LINDSEY BERGMAN, PH.D.
· JOHN PIACENTINI, PH.D.
· JAMES T. MCCRACKEN, M.D
To examine the prevalence of selective mutism (SM) in a public school sample and compare the functioning and symptoms of children with SM to age-and gender-matched unaffected children.
Kindergarten, first, and second grade teachers in a large district were asked to identify pupils who met DSM-IV criteria for SM and to complete ratings of speaking behavior, social anxiety, other internalizing and externalizing symptoms, and overall functioning for these and comparison youngsters. Teachers completed the same ratings on the SM children 6 months later.
A participation rate of 94% (125 of 133 teachers) was obtained, and the prevalence of SM was .71% (16/2,256). Measures were completed for 12 (75%) of 16 identified children. Compared with peers, children with SM were more symptomatic on measures of frequency of speech, social anxiety, and other internalizing symptoms. As a group, children with SM had improved 6 months later but remained impaired and symptomatic when compared with the comparison group.
SM may not be as rare as previously thought. The functioning of children with SM is impaired, and although there is some improvement over time, notable impairment remains, suggesting that intervention is preferable to waiting for SM to remit spontaneously.
J Am Acad Child Adolesc Psychiatry. 2003 Dec;42(12):1451-9.
Prevalence and description of selective mutism in immigrant and native families: a controlled study.
Elizur Y, Perednik R.
Psychology Department, The Hebrew University, Jerusalem, Israel.
To assess the incidence of selective mutism (SM) in West Jerusalem’s state preschools and evaluate social anxiety/phobia disposition (SAP), social competence (SC), markers of neurodevelopmental delay/disorder (NDD), mothers’ psychological adjustment, and marital conflict in immigrant and native children with SM and their matched controls.
Mothers of 9 immigrant and 10 native children with SM and their matched controls completed questionnaires evaluating themselves, their marriages, and their children.
A response rate of 30% (19/64) was obtained. The general prevalence of SM was 0.76%, while the rate among immigrants was 2.2%. Except for mothers’ adjustment, all immigrant/native group effects were significant. There were significant interactions between the SM/control and immigrant/native groups for SAP, NDD, and SC. Immigrant children with SM had higher SAP and SC scores and lower NDD scores than native children with SM.
This study distinguished between homogenous (socially anxious) and comorbid children with SM. In this sample, the disorder appeared to be associated with a combination of a specific diathesis (SAP) with intrinsic (NDD) and/or environmental (family immigration) vulnerabilities. Marital discord appeared to be a general risk factor for SM.
SM – Selective Mutism
SMRM – Selective Mutism Resource Manual (Johnson & Wintgens, Speechmark, 2001) Carmody – Research article originally published by L. Carmody
All quotations are referenced within the text.
Endnotes are included here:
* Carmody: Source: SMRM, 2001 Johnson & Wintgens adapted from Carmody 1999, Lorraine Carmody, School of Clinical Speech & Language Studies. Trinity College, Dublin, Ireland.