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Selective mutism: a consensus based care pathway of good practice
  1. D V Keen1,
  2. S Fonseca1,
  3. A Wintgens2
  1. 1
    St George’s Healthcare NHS Trust, London, UK
  2. 2
    Child and Adolescent Mental Health Service, South West London and St George’s Mental Health NHS Trust, London, UK
  1. Dr D V Keen, Rm 2.35, 2nd Floor Clare House, St George’s Hospital, Blackshaw Road, London SW17 0QT, UK; daphne.keen{at}


Background: Selective mutism (SM) now acknowledged as an anxiety condition, tends to be a poorly understood, highly complex and vastly under-recognised clinical entity. Children with SM are a vulnerable group as the condition is not the remit of any one professional group. This inevitably leads to delay in formal diagnosis and management. There is a lack of systematic research on which to base guidelines for management.

Aim: To develop, agree and validate key principles underlying the management of SM through a consensus process involving international experts, in order to create a local care pathway.

Methods: A local multi-agency consultation process developed 11 statements, which were felt to be the key principles underpinning a potential care pathway for managing SM. Thirteen recognised experts from North America, Europe and Australia participated in a modified Delphi process involving two rounds using a Likert-scale and free commentary. Both quantitative and qualitative analyses were used in the validation or revision of the statements at each stage.

Results: Response rates were 100% for Round 1 and 84.6% for Round 2. Despite the differing professional backgrounds and service contexts, by successive revision and/or revalidation of statements, it was possible to arrive at a consensus about key principles relating to early recognition, assessment and intervention. The agreed key principles are presented together with the resulting local care pathway.

Conclusion: Through a Delphi process, agreement was reached by a multidisciplinary group of professionals, on key principles that underpin the timely identification, assessment and management of children with SM. These include the potential for staff in school/preschool settings to identify SM and that intervention programmes should generally be based in these settings. Children with SM should receive assessment for possible coexisting disorders, whether developmental, emotional or behavioural and additional specific intervention given for these. Agreement was reached as to what constitutes clinical progress, intervals for monitoring progress, criteria for referral onwards for multidisciplinary specialist assessment and the role of selective serotonin reuptake inhibitor (SSRI) medication.

A consensus methodology has been successfully used to compensate for the lack of evidence base and harness the expertise of a relatively small number of experienced professionals in order to provide a basis for the future development of services.

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  • Competing interests: AW is coauthor of Johnson M, Wintgens A. The selective mutism resource manual. Speech Mark Publishing Limited, 2001.

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