Info:
Guidance for the Diagnosis of SM

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Guidance for the Diagnosis of SM

One question that comes up frequently, with relation to Selective Mutism, is how can we diagnose SM in a case where the patient also has a diagnosis for another condition? At SMIRA we see many cases of co-existing SM with other conditions and/or autism. Many of the diagnoses of SM precede autism assessments, although some SM assessments do come after an autism assessment. The problem we see is that in some cases the SM assessment is not performed because it is assumed that the autism assessment is enough to explain all of the behaviours apparent in the patient.

SMIRA’s position on diagnosis of SM

1. Diagnosing practitioners should make an assessment for SM where they believe the patient meets the criteria for such a diagnosis.

The preferred diagnostic criteria prior to the publication of ICD-11 in 2018 were those published in APA DSM5, which lists SM as an anxiety disorder.   ICD-11 classifies SM as an ‘Anxiety or Fear Related Disorder’.   It lists as exclusions:

• Schizophrenia 
• transient mutism as part of separation anxiety in young children 
• Autism spectrum disorder 

Exclusions in the context of ICD-11 are ‘terms which are classified elsewhere’ and which ‘serve as a cross reference in ICD and help to delimitate the boundaries of a category’.  This means that SM and autism are classified separately and can therefore be diagnosed as co-morbid.   This differs from the definition of exclusions used in DSM5 as ‘does not occur exclusively’. 

1. Diagnosing practitioners should make a separate diagnosis for SM even if there is a pre-existing diagnosis for another condition. SMIRA believes that ‘excluding’ SM as a comorbid diagnosis in DSM5 has been very unhelpful to medical practitioners and their patients. This is especially true in the case of autism. We believe a person who is autistic can also have SM, and this is allowable using ICD-11 classification.

This position is made clear in The Selective Mutism Resource Manual 2^nd Edition and in Tackling Selective Mutism, the latter being endorsed by Professor Sir Michael Rutter (Institute of Psychiatry, King’s College London).

 

Alice Sluckin and Benita-Rae Smith (2016)

Revised Shirley Landrock-White (November 2018 and January 2025)

 

References:

https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/167946871 

(Accessed 6/11/18)

The Selective Mutism Resource Manual 2^nd Edition, Johnson & Wintgens, Speechmark Publishing Ltd, London (2016)

Tackling Selective Mutism, Smith and Sluckin, Jessica Kingsley Publishers, London (2015).