1. Introduction
In the book Tackling Selective Mutism (Sluckin, Smith, 2014) from the chapter on Care Pathways, written by Maggie Johnson, Miriam Jemmet and Charlotte Firth, there is a section which states:
Page 183: First section.
“Services (UK) are aware that by dispelling the myth that it is safe to wait for young children to ‘outgrow’ SM, the need for more costly or extended intervention at a later date will be reduced.”
Opinion
To me, this is a very clear statement that young children should not be left without specific support, they will not just ‘outgrow’ SM. Those responsible for their care should not leave an SM child without the support, care and therapy that they need. To me, it is a myth.
The myth should/must be dispelled in order to prevent the long term effect of SM which will be more costly to treat than it would be if it has been treated effectively in early years.
The cost is not purely the cost of later treatment, for potential depression for example. This cost can be measured by the health service in question in financial terms, but it should also be measured in the human cost: the effect on a human being of being left without the correct diagnosis and treatment. The human cost is unmeasurable in financial terms. Our children are priceless.
Preventative medicine is lower cost than delayed or reactive medicine. Proactivity has a cost but it is usually cheaper than reactivity and the degeneration of someone’s health. We are talking about mental health, in the main. The problem, in the future for some can degenerate from mental health to their physical well-being. Depression can lead to selfharm, overdose or worse.
SM is identified internationally by the APA DSM5, the UN-WHO ICD-10 and therefore the diagnostic criteria are visible around the World.
What follows is my own take on the debate, which I base on the above quotation. One thing leads to another. This document also discusses the effect of change on SM and suggests a few things to think about.
2. Outgrowing SM
I begin this section with a series of questions to promote the debate:
- What does it mean to outgrow SM?
- Does a child get older, and suddenly at a certain age the SM disappears?
- Is the anxiety that drives SM age dependent, so that it disappears at a certain date, or when the child reaches a certain physical state, weight, height or puberty?
- Can a child make a conscious decision to break out of the SM cycle?
I don’t believe that children just outgrow SM. It doesn’t just disappear independently.
Personally, I’m very tall. I was a ‘refuser’ at pre-school age. I took entry to primary school very badly but my mum will tell you that the only thing I ever grew out of was my trousers and my hand-knitted pullovers. I was lucky to have some good teachers to help me overcome my school anxiety. One of those teachers remains a close family friend to this day. She will tell anybody that my sister was in her class and famous for blooding the nose of one of her 5 year old classmates, while I was in the room next door unhappy with the separation from my mum after 4 years of 24/7 care and affection.
A myth is a myth. It’s a story which is untrue. Mythical monsters with eight arms? It’s just fiction.
Anecdote 1
I recently discussed outgrowing SM with someone who said they out grew SM.
“I did, A change of schools following a house move aged around 7 did it for me”.
Was it because they reached the age of seven that the SM disappeared, or was it the house move, or maybe the new school?
Personally, I’d say that the SM was associated with school space before the age of seven, and the opportunity to go to a new school removed the associations this person had with anxiety in the old school. The cause of this young child’s anxiety was removed by change.
The new school didn’t have the same feeling as the old one, the old school being where the SM began. SM is selective by definition, that first school was the place where the SM occurred. The second school was a new environment, a new space without those old associations and without the mutism. Similarly, moving house can have both a positive and/or negative impact.
At this point I usually say that this child moved from one space to another, from an anxious space to a non-anxious space. This is nothing to do with outgrowing SM, this is everything to do with the selective nature of SM and the word ‘change’ which I’ll come to in a later paragraph.
Anecdote 2
A teenage boy overcomes his SM by himself. Somebody told me this story. It would seem that peer pressure played a part in motivating the teenager to overcome his mutism. He was no longer willing to miss out on what his peer group were getting up to. The pressure to join-in overcame the anxiety associated with speaking. The influence of an external factor may be significant in this case.
Again, a change occurred and affected this teenager. His friends changed. They moved their focus onto other things. He was left alone. He had the chance to follow them and succeeded. Did he outgrow SM or did his environment change?
Anecdote 3
I talk a lot about my own daughter MissT (12, ex-SM). Using her as an example as I try to explain something.
I changed a number of things in her life. These are visible in the next section of this document. I dictated those changes on her life, and I regret none of them. Maybe one day she’ll tell me I made a mistake which is fair enough. On the whole I’d say I’m happy with the end result, although at nearly 13, there’s more to come in terms of change.
Recently the admins in the SMIRA FB group were debating the idea that someone could outgrow SM. On behalf of the team, I’m happy to say that we prefer the term ‘overcome’ ahead of terms like ‘cure’ or ‘outgrow’.
3. The effect of risk and change on SM
Personally, and professionally I spend a lot of my time thinking about the subject of change. As a student of history at University change is visible across the ages. Single individuals are able to effect changes which impact entire nations, continents, peoples, religions. Change is part of our history. Nothing is ever the same forever. Things change.
Some changes are out of our control, others can be managed. SM is driven by anxiety. Anxiety occurs at different levels at different times, and in different places. SM is selective in the sense of the situation, not a choice, but driven by anxiety.
Carmody* identified 3 groups of factors which can influence someone with SM. I call them the 3P’s and have discussed them in other documents.
Each factor on the Carmody list is a risk. The risk that it might cause increased anxiety. Each risk has an effect if it occurs. Not all risks occur. Some never occur, others can be avoided, reduced, transferred. We can all mitigate risks once they are identified. We can identify responses to a risk based on a ‘what-if’ scenario. If a risk occurs, then we have to deal with the effect.
If we are proactive about risks, we can make a change. Changes can be made. Change is risk mitigation. If we are reactive about risk, we will be too late.
One of the biggest questions about change related to SM has to be whether the child is informed of the change, if it is proposed by a parent or professional. Would you discuss moving house with a young child, or just make the decision with the best intentions and get on with it. Does a young child’s opinion matter? What about a teenager? Can an SM adult make a ‘change’ decision or does the anxiety preclude this? What if you have to change, you don’t have the choice and you are forced to change something?
Unexpected changes happen too. Some changes our unpredictable, out of our control. They happen. They might be traumatic in one extreme or might be the slightest changes at the other end of the change spectrum.
– A teacher who is absent or off sick for a day is a temporary change and raises anxiety but it is by nature ‘unexpected’ on that day. It’s part of life.
If you have to change, you can look at a change forever, but eventually a decision has to be made.
What is a change?
A change alters something.
You might change clothes, food, house, school, car, partner, job, the list is endless. Everything can be changed.
Change can be described in a cyclical way, as per the following figure which starts with the question Why?
Figure 1: Change cycle
4. Timelines
I use timelines a lot at work. They help to describe events over a period of time in a visual way and allow a multi-agency group to get around the table and see things together. This is one way of looking at the effect of changes.
Individually we could all describe our own timelines. A sequence of events over time including birth, starting school , getting a job, reaching a landmark birthday, retiring etc. Each timeline, sometimes unfortunately, comes to an end.
The basic elements of a timeline are
– A line with the time period marked on it
– Events or milestones can be marked on that line
– Phases or stages along the timeline. This might include future plans or past periods of time.
The following timeline as a real SM timeline for a certain person I know very well. I have simplified it and removed a lot of details from the original in order to make it more generic.
The features of this SM Timeline are the points at which change occurred over the timeline. The milestones are clear. The changes were dictated. There was no concept of giving the child a choice in any of this before the age of 8.
Milestones
– SM day 1 (onset of SM, first anxiety attack)
– Divorce
– Diagnosis of SM by a professional Ed. Psych.
– Plan start date
– Generalisation start date (vertical line)
Changes
– First day at nursery
– First day at kindergarten
– Divorce (yes it was a significant change in the timeline)
– First day at primary
– Teacher transition 1
– Teacher transition 2
SM Timeline
5. Planning Change
In this timeline there are a number of plans which were set and implemented. These were not all beneficial:
– Plan to start kindergarten (Dump and Run strategy)
– Plan to start pre-school (No introduction session)
– Plan to start primary (No introduction session)
– Plan to start SM therapy (No communication to the child)
Aged 6, I decided to NOT communicate the plan for SM therapy, in conjunction with school staff. It worked. Their own internal processes were already in place, and adding knowledge from the SMRM helped that programme.
Recommendations for planning these kinds of changes include items such as
– TAC Team Around the Child
– Gradual exposure of the child to the new situation (Stimulous fading, or formal sliding-in)
– Awareness knowledge transfer to those in the TAC
– Age appropriate discussions with the child about the planning etc.
A plan should have
– Reason (Why)
– A defined end result (What)
– An organisation (Who)
– Defined target benefits (How much)
– Defined stages or steps along the way (How)
– Regular communications to the organisation
– Flexibility in the event of unexpected events. (All plans change)
I did not put the ‘When’ in this last list.
If the change is unexpected, you still have to do the ‘How do I live with the change?’. In all cases I adopt and adapt any good ideas. Whatever the idea is. Adapt the idea to the situation you are in.
Where would MissT be today if I hadn’t dictated some changes on her life? If I hadn’t been given the SMRM? If I hadn’t have had the support from school? Would she have grown out of SM? She’s tall like me. She grows out of her clothes too. She overcame her SM with a little help … Like it says at the bottom of the page, I’m just a dad 😉
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*Carmody L. The Power of Silence: Selective Mutism in Ireland – a speech and language perspective. Journal of Clinical Speech and Language Studies, 2000;1,41-60
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I’m just a dad
