Selective mutism — OSCE

Objectives

1. Elicit the setting-specific speaking gradient and frame selective mutism as an anxiety-driven freeze, not defiance. [14]
2. Confirm hearing and language adequacy, and screen comorbidity and safeguarding. [14]
3. Explain the diagnosis to the parent and teacher without stigma. [14]
4. Agree a behavioural-intervention-first plan with school collaboration, and describe when an SSRI is added. [5]

Candidate brief

12-minute station. Parent and child attend after the teacher flagged that the child has never spoken all year. The parent says "she never stops talking at home" and is worried the staff think she is being defiant. The child hides behind her mother, nods and points but produces no speech. No prior formal mental health assessment. [14]

Expected actions

• Engage the child gently through the parent or play; avoid any pressure to speak. [14]
• Elicit the speaking gradient: where she speaks, whispers or stays silent across home, relatives, friends, classroom and playground. [14]
• Explain that selective mutism is an anxiety-driven freeze, not defiance or mere shyness, and that the setting-specificity is itself diagnostic. [14]
• State the mandatory hearing assessment and confirm adequate spoken language at home. [14]
• Describe first-line behavioural intervention — stimulus fading, shaping, positive reinforcement, defocused communication — delivered collaboratively with the school, with pressure to speak removed. [5]
• Mention the SSRI option for moderate-severe or comorbid illness at review, with a clear safety-net for mood, self-harm or deterioration. [13]

Examiner prompts

• "Teacher thinks she is just being stubborn." → Reframe the freeze as anxiety, not defiance; psychoeducation of staff is part of treatment. [14]
• "Will tablets fix this?" → Behavioural intervention is first-line; medication is added for moderate-severe or comorbid cases, not substituted for behavioural work. [5]
• "Should we just wait — she might grow out of it?" → Persistent setting-specific silence warrants active treatment; delay deepens impairment and secondary depression. [14]

Marking foci

• Child-centred, pressure-free engagement and speaking-gradient mapping [14]
• Mandatory hearing assessment and language-adequacy check [14]
• Stigma-free psychoeducation framing anxiety rather than defiance [14]
• Behavioural-intervention-first plan with genuine school collaboration [5]
• Appropriate SSRI framing and safety-netting [13]
• Clear, safe follow-up plan [14]