Selective mutism — school silence and stepped care (MEQ)

(i) Assessment priorities. Map speech-versus-silence settings (home fluent; school mute for 5 months — exceeds ≥1 month and is not limited to first school month). Confirm impairment (education, social communication). Apply criterion D carefully: bilingual status requires assessment of knowledge of and comfort with classroom English — here comprehension is present but practice with non-family adults is limited; still formulate SM if pattern holds after language comfort is addressed. Obtain hearing screen, developmental language history, ASD trait screen, trauma/bullying screen, family anxiety history. Collateral: teacher speech frequency, home video of speech capacity, SMQ/SSQ-style measures. MSE with parent present and, if possible, observation of freeze response. Risk low for self-harm here but document mood; safeguarding if history shifts. Do not accept "tablet only / no school work" as a complete assessment plan.^[1][2]

(ii) Working diagnosis and differentials. Working diagnosis: selective mutism (anxiety disorders chapter conceptualisation) with classic school-entry presentation and high accommodation. Differentials: residual second-language discomfort (partially addressed by comprehension testing but ongoing practice needs monitoring); social anxiety disorder without SM (she fails to speak, not only fears evaluation while still speaking); language disorder (speaks full sentences at home — less likely sole cause); hearing impairment (must exclude); ASD (broader social-communication deficits/RRBs — screen, can co-occur); ODD/wilful refusal (freeze/anxiety signs argue against pure oppositionality); trauma-related mutism if history emerges. Discriminators: capacity present at home + situational failure when speech expected.^[1][2]

(iii) Psychological/school plan. First-line behavioural/CBT package with school involvement: psychoeducation (anxiety not naughtiness); speaking hierarchy (non-verbal → whisper to parent in class → brief word to teacher → peer speech); stimulus fading, shaping, contingency management, defocused communication; reduce accommodation (teacher and peers stop permanently answering for her; use wait-time and prompts). Align with packages such as IBTSM principles and Oerbeck home/school programmes. Parent coaching is mandatory; clinic-only work without school is incomplete.^[3][4]

(iv) Medication. Not first-line sole treatment. If severity high or partial psychological response, specialist/CAMHS-supervised fluoxetine (most studied SSRI in SM): start 5–10 mg orally once daily, titrate slowly toward a tolerated effective paediatric range often discussed around 10–20 mg/day (individualise), concurrent with behavioural work. Monitor activation, suicidality, sleep, GI effects early; frequent early reviews. Black RCT and open series support benefit signals; Kaakeh review summarises SSRI focus. Avoid promising a tablet that "forces speech by next week."^[5][6]

(v) Forced speech and disposition. Decline public forced performance/shaming as non-equivalent to graded exposure and potentially harmful. Offer collaborative hierarchy with school liaison. Disposition: CAMHS/psychology + school plan + audiology + GP shared care; step up if non-response, new risk, or dual ASD/language needs. Early intervention improves odds (younger age advantage in Oerbeck data).^[3][4]