Intended for healthcare professionals

Fillers A patient who changed my practice

The internet and a “small miracle”

BMJ 2000; 321 doi: (Published 15 July 2000) Cite this as: BMJ 2000;321:165

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  1. Di Jelley, general practitioner
  1. North Shields

    I have just returned from a mother's day concert at my 6 year old's primary school. The first “welcome” statement was made by a friend of hers, A, in a loud clear voice—a remarkable achievement for this particular child.

    I have known A since she was a baby, watching her and two younger siblings pass through the baby clinic and reach normal development milestones. A was always a quiet child in company, but I was surprised to hear my daughter, in A's class at nursery, remark one day, “You know Mummy, A never speaks at school.” There was no hint of developmental delay, and at home A interacted quite normally with her family. The transition to primary school saw a persistence of A's determined silence—no verbal interaction at all with her class mates or her teachers, although her basic literacy and numeracy skills developed in line with those of her peers.

    A's parents were worried but remained patient and expectant—they at least knew her much more normal behaviour at home. By the beginning of her second year at school A had still not uttered a single word at school. She also refused to remove her shoes and socks for physical education in front of others and would eat nothing all day, neither school dinners nor a packed lunch. A's parents asked for a specialist review, wondering if any form of therapy would lead to more normal childhood interaction. No specific help resulted from this psychiatric assessment, but at least A now had a label “selective mutism,” and in today's world a label by itself can begin to unlock doors.

    I have to say my heart sank a little at the sight of sheets of internet printouts in A's mother's hand when she came in to see me a couple of weeks after the psychiatric clinic appointment. This was not because I resent patients accessing health information but because I don't know how to judge the quality or validity of this information—I don't know how to use it to make clinical decisions. But I was impressed. A series of case reports and parents' stories of children seemingly similar to A who had responded dramatically to short courses of fluoxetine.

    This drug is not licensed for children in the United Kingdom, but our local drug information pharmacist was able to locate a small trial describing its use in children with selective mutism.1 A's parents and I talked about the concerns relating to the use of unlicensed medication, and I thought that I had to share my reservations explicitly, drawing up a clear contract acknowledging our shared responsibility in using this drug on their child.

    Within two weeks of starting the drug, A was recording taped messages for her teacher and beginning to participate in physical education. After six weeks she is chattering happily with her friends at school and has been to her first party alone. She has been transformed into a totally “normal” 6 year old, and her parents are slowly withdrawing the fluoxetine.

    I am convinced that the use of fluoxetine has played a central part in this huge change in A's behaviour, and I am equally sure that without the internet her parents could not have accessed this information. So if my heart sinks again at the sight of a patient's internet printout, I will simply remind myself of the small miracle of A and suspend my prejudgment.

    We welcome articles of up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for “Endpieces,” consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.


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