My medical assistant put the chart on my desk. “your next patient is in room five, Dr. Cohen. Her name is Taylor and
she’s a cutie!”
“Thanks, Mary,” I said, pulling up Taylor’s medical record on my desktop computer. I glanced at the consultation request: Six-year-old girl with speech problem. As a developmental pediatrician, I am often called on to evaluate children’s speech and language. Those are among the most complex tasks the young brain has to master, so it’s no wonder many childhood disorders express themselves in those areas. Kids with developmental delay or autism commonly show up in the pediatrician’s office with a parent who simply says, “My child isn’t talking.”
When I opened the door to the examining room, I saw a petite girl with long, blond hair sitting very still on the exam table. She wore a purple jumper over a short-sleeved white blouse, and her hair was tied at the back with a ribbon that matched her dress. She was deeply engrossed in reading a Dr. Seuss book. She looked up at me and smiled.
“Hi,” I said. “I’m Dr. Cohen. What’s your name?”
The girl continued to smile, but she didn’t say anything and quickly went back to her reading. Hmmm. Could just be a shy one, I thought. I turned to her mother.
“I understand your daughter is having some problems with her speech. Can you tell me what your concerns are?”
The mother was also petite and neatly dressed. She looked directly at me and said, “Well, she seems to have trouble talking.”
OK, maybe I was wrong. This was probably a child with some articulation problems. “What kind of trouble?” I asked.
The young woman grimaced slightly before answering. “Well, she, uh…she doesn’t talk.”
Maybe I wasn’t so wrong after all. Not talking is a complaint I hear from parents of children who turn out to have severe speech and language disorders. But those conditions generally declare themselves before age 6. Something was different here.
“No, not at all. At least that’s what her teacher says.”
“Her teacher? So she doesn’t talk at school?”
“Not a bit.”
“What about at home?”
The girl’s mother shook her head with a rueful grin. “At home I can’t shut her up! She talks a mile a minute.” She paused, and the grin faded. “I just don’t understand it.” Apparently Taylor’s pediatrician had not understood it either, but her mother had just given me the key. I was pretty sure I knew what was keeping this child quiet. Now I just needed a little more information to confirm my diagnosis.
“How about when she’s somewhere else, like the mall—does she talk then?”
“No, not a peep. When she was younger she talked all the time, and everywhere. Then when she was about 3 she started getting quiet. We would go out to eat and she wouldn’t say a word the entire time we were at the restaurant. At first we just thought she was shy and we encouraged her to talk, but she would just sit there. So we just gave up.”
I turned back to the girl. “Hi, Taylor! That’s a pretty dress you have on.” She looked at me with a faint smile. “I bet you like purple.” Her smile broadened. “Hey, your mom is wearing a purple skirt. Is it her favorite color too?” She nodded slightly, and then her smile faded and a wary look came into her eyes. Realizing I had made her uncomfortable by asking a question, I quickly shifted gears. “Green Eggs and Ham—I read that when I was a kid. I bet you like to read.” She smiled again and nodded vigorously.
“You see?” her mother asked with a worried expression. “This isn’t normal, is it?”
“No, it isn’t,” I said. “But I think
I know what’s going on here and what we can do to help.” Strictly speaking, Taylor didn’t have a speech problem at all.
The telltale symptom was that Taylor talked perfectly well when she was at home but went silent when she was away from her familiar environment. She had a classic case of
a condition called selective mutism.
I’ve had a handful of patients with selective mutism in my 30 years of practice, and I’ve seen our understanding of this condition increase dramatically over that time.