Selective mutism — viva

Stem

Examiner-led viva on selective mutism. [14]

Examiner: How do you open this "never heard her voice all year" presentation? [14]

Strong answer: I take a multi-informant history — the parent about home speech, a structured teacher report about school — because the diagnosis lives in the gap between the two. I engage the child gently through play or her mother and avoid any "say something for me" demand, since pressure re-creates the freeze. I frame this as a full assessment, not a same-day label. [14]

Examiner: What defines this as selective mutism rather than shyness or defiance? [14]

Strong answer: The setting-specific, anxiety-driven freeze: a child who speaks fluently and appropriately at home but is consistently silent in specific demanding social settings such as school, for at least one month, with interference in education or social communication, and not explained by a communication disorder, language-comfort issue, autism or psychosis. Shyness resolves in weeks without impairment; defiance implies a choice, whereas this is a "can't". [14] [15]

Examiner: What is the one investigation you will not skip? [14]

Strong answer: A hearing assessment. A child who is silent because of undiagnosed hearing loss or glue ear has a communication problem, not an anxiety disorder, and must never be labelled with selective mutism. I also confirm adequate spoken language in at least one home language. [14]

Examiner: What is first-line treatment? [5]

Strong answer: Psychoeducation — selective mutism is an anxiety condition, not defiance — plus collaborative behavioural intervention: stimulus fading, shaping, positive reinforcement and defocused communication delivered with the school. The Cohan practitioner review positions behavioural intervention as first-line, and the family and school collaborate to lower the social-evaluative demand while keeping graded speaking opportunities alive. [5]

Examiner: When and what do you add pharmacologically? [1]

Strong answer: For moderate-to-severe illness, an inadequate behavioural response, or heavy comorbidity such as social anxiety, I add an SSRI — fluoxetine is the most-studied agent, supported by the Black and Uhde double-blind RCT. I start low, titrate over weeks, and monitor activation, sleep, weight and suicidality, documenting baseline ideation and screening for bipolar history. [1] [13]

Examiner: How do you distinguish this from social anxiety disorder? [11]

Strong answer: The two overlap so heavily that selective mutism is conceptualised as the severe, early-onset form of social anxiety, and they frequently coexist. The distinction is one of developmental timing and severity rather than category, so I assess and treat both rather than waiting for the mutism to resolve in isolation. [11] [15]

Examiner: What if the silence had begun acutely last month with withdrawal and regression? [14]

Strong answer: That is atypical for selective mutism, which is chronic and setting-specific. I would reconsider the diagnosis: exclude abuse and safeguarding concerns, an acquired neurological cause and a psychotic process, and address safety first before any behavioural or pharmacological treatment. [14] [5]