Part I – Theoretical Approaches
1 What is (Selective) Mutism?
1.1 Definition and Appearance
The word „mutism“ comes from „mutus“ (Latin), meaning silent. For the well-known phenomenon of persistent silence the following designations are found in the literature:
Aphasia Voluntaria (Kussmaul 1877)
Voluntary mutism (Gutzmann 1894)
Total/elective mutism (Tramer 1934)
Elective mutism (ICD-10, F94.0)
Selective mutism (SM) – Selective mutism (DSM-IV)
Partial/Universal silence (Schoor 2002)
Mute children usually have the ability to speak. But they do not employ this in situations unfamiliar to them, in specific locations and/or with a specific group of people. They fall silent, freeze or communicate consistently and exclusively by means of gestures, facial expressions or written communications (Hartmann 1992).
„Selective Mutism is a disorder of childhood characterised by the total lack of speech in at least one specific situation (usually the classroom), despite the ability to speak in other situations” (Dow et al. 1999, 19).
In the guidelines of the German Society for Child and Adolescent Psychiatry, the following definition is given:
„Elective mutism is an emotional disorder of verbal communication. It is characterised by selectively talking with certain people or in defined situations. Articulation, receptive and expressive language of those affected are generally within the normal range, at most they are – based on the stage of development – only slightly impaired“ (Castell/Schmidt 2003).
Hartmann (Hartmann 1997 based on Tramer 1934; Böhme 1983) distinguishes between total mutism and elective mutism. Total mutism is a total refusal to use spoken language while hearing is preserved, but more often occurs as a secondary symptom of psychotic disorders, major depressive disorders, etc. Talking and any other noise generated in the mouth, such as clearing the throat, coughing or sneezing is avoided in contact with all persons. Total mutism occurs extremely rarely in children. In elective mutism (Tramer 1934) certain people or definitely circumscribed contexts are chosen with whom or in which talking is avoided (Friedman/Karagan 1973;Böhme 1983; Biesalski/Frank 1983; Becker/Sovàk 1983).
Elective mutism, on the other hand, is the commoner and more familiar disorder in which „after language acquisition has taken place, there is a denial of spoken language to a particular group of persons“ (Hartmann 1997, 57). Castell and Schmidt recommend that as total mutism is rare not to count it as a separate group, but as a specific expression of mutism (Castell/Schmidt 2003, 1).
This book deals primarily with children with selective mutism. In order not to exclude children with total mutism, we will use the phrase (selective) mutism, and when repeated only the term „mutism“ is used.
The transition in the use of the terms elective to selective mutism, which has taken place in the literature in the last forty years (Popella 1960; Asperger 1968; Böhme 1983; Saloga et al. 1983; Hartmann 1997, 22f.) requires a more comprehensive explanation.
The term elective suggests a freedom of choice about with which people, in what circumstances and at what locations talking takes place or not. Seen subjectively, in selective mutism such freedom does not exist. If a preschool or elementary school child encounters a situation in which it consistently refuses to speak and says nothing as its „coping strategy“ (Bahr 1996), then we cannot speak of any voluntary nature in the traditional sense (Spasaro/Schaefer 1999, 2). It often requires considerable effort every day to fight the temptation to speak, to endure and maintain silence. And with both early mutism (4–6 years) and late mutism (6–8 years) we cannot speak of a conscious choice of a behavioural strategy, but rather of an intuitive solution. In an unfamiliar social situation, the child reacts according to the available behavioural repertoire that has been generalised (in the sense of Gehm 1991;Roth et al. 2010;Meroe 2002; Roth 1995; Roth et al. 2010). Thus, the use of the word elective could lead to trivializing the persistence and severity of the disorder. With parents, teachers and members of the family, this helplessness in the face of iron silence produces an angry response (Hartmann 1997, 40). This anger usually leads to a reinforcement and maintenance of the behaviour.
The issue of whether the mutism is voluntary is answered in recent literature sources from the U.S. and Great Britain as involving an anxiety disorder in the form of a social phobia, infantile childhood depression or a compulsive act (Hayden 1980; Dow et al 1999;. Kristensen 2000; Hartmann/Lange 2010; Yeganeh et al. 2003;Sharp et al. 2007; Carbone et al. 2010). In this type of disorder, the child is standing as it were under a „spell“ or under pressure to cease speaking at certain locations or in certain situations and not to utter a sound. Such compulsion does not appear to be susceptible to voluntary control.
There is also further discussion in recent Anglo-American literature of a neurological aspect, arguing for a drug treatment as part of therapy. The suggestion is to use drugs from the group of anti-depressive agents combatting compulsion and anxiety such as „Clomipramine“, „Fluvoxamine“ and „Prozac®“ (Rapoport 1989; Wright et al. 1999). The need for drug therapy and long-term effects are controversial. Further, responsible research is certainly required, also on long-term effects, in order to clarify these relationships (see Manassis/Tannock 2008).
What, then, is selective mutism? The following definition can be found in the ICD-10 (Remschmidt/Schmidt 1994, 108):
F94.0: Elective Mutism
„A disorder that is characterised by a distinct, emotionally induced selectivity in speaking. The child shows his language competence in some situations but not in other situations. In most cases, the disorder first appears in early childhood. (…)
Most mutism is connected to significant personality characteristics, such as social anxiety, withdrawal, sensitivity or resistance. (…)
Typically, the child speaks at home or with close friends, but is mute at school or with strangers. (…)
Related term: selective mutism
It should be noted:
- Transitory mutism as a part of separation anxiety disorder in young children (F93.0)
- Specific developmental disorders of speech and language (F80)
- Profound developmental disorders (F84)
- Schizophrenia (F20)“
(ICD-10 1994, F9: behavioural and emotional disorders with onset in childhood and adolescence)
In the current literature, mutism is increasingly associated with anxiety and social phobias (Dow et al. 1999).
1.2 Diagnostic Criteria
- „Persistent inability to speak in certain situations (where speaking is expected, for example, at school), although normal speaking ability is present in other situations.
- The disorder hinders educational or work-related performance or social communication.
- The disorder lasts at least a month (and is not limited to the first month after starting school).
- The inability to speak is not due to a lack of knowledge of the spoken language which is required in the social situation or the fact that the person does not feel comfortable in that language.
- The fault cannotbe better explained as a communication disorder (e. g. stuttering) and does not occur exclusively during the course of a profound developmental disorder, schizophrenia or other psychotic disorder.“
(Sass et al. 1998, 155f.)
As mentioned in ICD-10, we often see children whose other language disorders are superimposed on mutism. In older psychoanalytic sources, the disorder is counted amongst hystericalphobia; in more recent findings it appears in neuroscience and brain research (see Hartmann 1997; 2002). As already mentioned, the state of research does not permit a linear, clear-cut etiology. Instead, organic and neurological components (Rapoport 1989), alterations in pre-, peri-and postnatal natural and exogenous factors, model learning, trauma, and/or cultural change and impediments to language acquisition are assumed to be mutually influencing, potentiating and favourable risk factors for the disorder (Hartmann 1997;Bahr 1996; Dow et al. 1999; Schoor 2002; Spasaro/Schaefer 1999;Kristensen 2000; Manassis et al. 2007).
The three forms of childhood fears are:
- separation anxiety disorder (extreme fear of separation from familiar caregivers),
- avoidance behaviour (excessive shying away from strangers, so that social relations are limited, shyness and lack of social contact) and
- over-anxiety disorder (excessive and unrealistic fears, coupled with feelings of extreme anxiety, obsessive worry about performance and general tenseness up to paralysis.
All of these forms are found in striking ways in mutism (see Thyer 1991, quoted by Petermann/Petermann 1996, 11f.). In the present debate about the classification of selective mutism as an anxiety disorder, Carbone et al. (2010, 1058) have advanced the following arguments, which can be summarised as:
- The high co-morbidity of both disorders,
- the high rate of anxiety disorders in the families,
- similar temperament characteristics of the two types of disorders,
- the similarity of the therapeutic measures.
We should nevertheless be warned against a hasty appraisal and stigmatisation as a result of a mono-causal diagnosis in early childhood. Etiological and diagnostic findings are beneficial if they are used to initiate therapeutic and rehabilitative measures and are relevant in supporting dealing with stress factors for parents and other people who are charged with educational responsibilities of the respective child.
This „idiographic“ aspect (Motsch 1996) is given special consideration in this book in its theoretical and practical considerations and approaches and also highlights the need for interdisciplinary cooperation and transdisciplinarity in planning and carrying out diagnosis and treatment.
1.3 Types of Mutism
There are various proposals on how to divide mutism in subgroups. The first important distinction is that between total and elective mutism (Tramer 1934, see Part I, Chapter 1.1)
Wallis (1957) organised the types of mutism according to etiological factors:
- mutism as a result of a psychosis
- mutism as a result of an organic brain abnormality
- mutism as a result of a psychogenic disorder
Biesalski (1973) tackles a mix of gradual appearance and etiology. Of interest here is the relationship of fluency disorders and mutism, which will be looked at later.
- Total mutism
- Elective Mutism
- Mutism as a result of an oral fluency disorder
- Mutism as a result of psychosis
Schmidbauer (1971) assigns the types of mutism according to the point in time of their appearance:
- Reactive mutism
Spoerri (1986) points to the need for a separation of childhood from adulthood:
- Mutism in childhood (regression)
- Mutism in adults (schizophrenia, catatonic states, depression, paranoia and hysteria)
This distinction is essential for both adult psychiatry and for pediatrics and pedagogy. For the purposes of reaching a diagnosis and deciding on a therapy, mutism in childhood must be classified differently because of developmental-psychological and language development-related reasons. This is a developmental disorder, indeed often appropriate, which is in most cases transient, although it should be seen as a disorder which should be taken seriously as a risk factor. Mutism should however be weighted differently the longer it lasts and the older the child is. The age at which the mutism occurs is divided into two groups:
- Early mutism (from 3;4–4;1 years)
- Late-/ School mutism (from 5;5 years)
This classification indicates that the disorder is always associated with a transition – from an intimate family- circle to an exposed position and connected with adaptation to and integration into a new social group (Bahr 1996, 37ff.; Hartmann 1997, 67f.)
Lesser-Katz (1988) distinguishes two main groups in children:
- compliant, timid, anxious, dependent insecure
- noncompliant, passive-aggressive, avoidant
The division by Hayden (1980), an American specialist for mute children who examined 68 mute children is therapeutically relevant and helpful. This identifies four types of mutism, which describe the appearance, behavioural problems and psychosocial causes in more detail:
„Symbiotic mutism characterised by a symbiotic relationship with a caregiver and a manipulative and negativistic attitude towards controlling adults.“
„Speech phobic mutism characterised by a fear of hearing one's voice accompanied by obsessive-compulsive behaviours.“
„Reactive mutism caused by a single depression and withdrawal.“
„Passive-aggressive mutism characterised by a defiant refusal to speak and the use of 'silence as a weapon'“ (Hayden 1980, cited in Grayson et al. 1999, 91f.).
This classification makes it clear that (selective) mutism has the common feature of silence. The etiology and the accompanying behavioural characteristics may be different in origin. This grouping by Hayden is questionable with respect to its suitability as a differential diagnosis (Kolvin/Fundudis 1981, 220; Bahr 1996, 22). However, it does help to differentiate therapeutic focus and allow considerations which help to access these children efficiently. This classification can also be helpful in working with families and with other professionals.
1.4 Epidemiology, Co-Morbidity and Risk Factors
Although (selective) mutism does not occur frequently, numerous applications have reached us at the Speech Therapeutic Clinic of the Technical University of Dortmund since it became known that we launched a research and treatment project (see Mutism Network: https://www.fk-reha.tu-dortmund.de/zbt/eng/spa/Mutism/index.html).
I had a similar experience in Switzerland in the years between 1975–1990: once a contact point opens, such requests increase and confirm the need for a place for specialised interdisciplinary treatment and information. Similar experiences have been reported by self-help groups in German speaking countries and we see that lively professional exchanges and in-service training and counselling activities are being held.
Epidemiological data in the literature puts the incidence variously as less than 0.1% (Fundudis et al. 1979) to 0.7% (Kos-Robes 1976) of clinically surveyed children (Hartmann 1997, 46; Bahr 1998, 39). Steinhausen describes as mute 0.5% of children with psychiatric abnormalities (Steinhausen 2000, further studies on this by McInnes et al. 2004).
In a first survey conducted by us in North Rhine-Westphalia in 2003, letters and e-mails were sent to 170 schools to ask for the number of mute children in schools. Returns by 50 schools brought the following results:
In the first grade classes (about 1,000 children in school enrolment) three children were determined to have selective mutism. This corresponds to an approximate value of 0.3% (Kunze/Konrad 2003).
In the remaining classes (about 5,000 children), there were four more children with selective mutism, two of them in normal schools (3rd and 4th grade) and two in remedial schools (7th or 8th grade) (Kunze/Conrad 2003).
This survey shows one of the lowest averages of any of the similar epidemiological studies in the literature. Of course account must be taken of caveats and qualifying statements, such as the interpretation of the response rate (we assume that the affected schools were more motivated to come forward) or the disproportionality in the first grade classes.
Whether mostly girls or boys are affected by (selective) mutism cannot be definitively ascertained. There are sources that proclaim a prevalence of girls (in a ratio of 1.6:1 to 2.6:1) (Wright et al. 1985; Lebrun 1990; Werder 1992;Cline/Baldwin 2004; Schoor 1996; 2001, 188). Other sources, however, refute this trend (Hartmann 1997, 47f.).
The duration of the disorder following its detection is 5;6 in girls, 4;0 years in boys, (Hartmann 1997, 69), irrespective of therapy. This again shows the need for the coordination of treatments. Because the process of education – albeit under difficult circumstances – must be guaranteed and ensured, cultural skills still need to be developed, and with them the seamless links to the choice of a career and social inclusion at the time of the solution of the disorder.
There are often also calls for hospitalisation. Studies on the improvement of the disorder using a stay in hospital speak of 62% of children aged three to eight years (Lowenstein 1979), in a group of children aged six to eight years the figure is 46% (Kolvin/Fundudis 1981). This indicates that hospital treatment has to be considered very carefully depending on the child, because it is not always efficient and can even lead to failure. This may adversely affect other therapeutic measures.
Additional problems (co-morbidity) in selectively mute children
Co-morbidity with other behavioural and psychiatric disorders is known to exist with the phenomenon of (selective) mutism (Luchsinger/Arnold 1970; Rösler 1981; Lempp 1982; Funke et al. 1978; Lesser-Katz 1988, Hartmann 1997, Kristensen 2000; Bar-Haim et al. 2004; Manassis et al. 2007 and others).
Castell/Schmidt (2003, 2) name the following co-morbid psychiatric side effects:
- Social anxiety
- Conduct disorder with oppositional behaviour
- Depressive symptoms
- Impaired regulation of sleep, food, excretory function or behaviour control.
In a study of 32 selectively mute children Rösler (1981, 188) found the following additional psychopathological abnormalities, and other features:
- Anxiety symptoms (90.6%)
- Passive withdrawal behaviour (63%)
- Mood swings (37.5%)
- Problems with concentration and performance (37.5%)
- Aggressiveness (28.1%)
- Hyperactivity (28.1%)
- Striking facial expressions and gestures (28.1%)
- Stubbornness (18.8%)
- Bedwetting (enuresis) (31.2%)
- Tics, jactation (restlessness), Stereotyped or self-stimulating behaviour (21.9%)
- Compulsions (21.9%)
- Encopresis (6.3%)
- Nail biting (Onychophagie), thumb-sucking and hair-plucking (trichotillomania) (40.6%)
Other findings regarding neurological abnormalities
- Pathological history (50%)
- Conspicuous history (34.4%)
- Inconspicuous history (15.6%)
- Clinical neurological findings (50%)
- Abnormal EEG (50%)
- Statomotor developmental delay (31.3%)
- Speech delay (65.6%)
- Speech disorder (46.6%)
- Visu-motor disorder (40.6%)
- Left-handedness (12.5%)
- Dyslexia (15.6%)
Steinhausen/Juzi (1996) found additional separation anxiety, sleeping and eating disorders in early infancy and in the preschool stage; Wittchen mentions other features:
„Extreme shyness, social isolation and withdrawal, clinging, truancy, compulsive behaviour, negativism, temper tantrums or other manipulative or oppositional behaviour patterns can be observed especially at home“ (Wittchen, 1989, 124).
Relevant for this are mainly the following „secondary features“ of selective mutism:
„Accompanying speech disorders as a developmental articulation disorder, expressive or receptive language impairment or a physical disorder affecting the ability to articulate, can be present“ (Wittchen et al., DSM-III-R, 1991, 124).
The following „characteristics“ can be found in the Anglo-American literature which are not mentioned in the diagnostic criteria of DSM-III-R:
- Excessive shyness
- Anxiety disorder
- Social isolation and withdrawal
- Maternal overprotection
- Symbiotic relationship with a parent (usually the mother)
- Language difficulties
- Early hospitalisation
- Memory span deficits
- Deficits in auditory efferent activity
- Maternal disharmony
- Fear of strangers (xenophobia)
- Manipulative, controlling or aggressive interpersonal style
(Hayden 1980; Kolvin/Fundudis 1981; Lesser-Katz 1986; 1988; Meyers 1984; Rutter/Garmezy 1983; Wilkins 1985; Wright et al. 1985; Grayson et al. 1999, 91f.; Mac Gregor et al. 1994).
This list shows that language disorders and deficits may be considered as a primary reason – or at least as risk factors – for selective mutism. Several older, but mainly current studies are able to prove that language abnormalities in selectively-mute children (Steinhausen/Juzi 1996; Kristensen 2000) (Bar-Haim et al. 2004) or impairment of other basic skills are linked to language development, such as auditory attention span. Selective mutism also occurs together with linguistic uncertainty due to migration (Elitzur/Perednik 2003; Kristensen/Oebeck 2006; Manassis et al. 2007; Toppelberg et al. 2005; Yeganeh et al. 2003). More recent studies show deficits and delays in developing pragmatic, social, communicative and/or narrative skills (Cunningham et al. 2004; McInnes et al. 2004; Carbone et al. 2010). These latter findings confirm my own long experience in diagnostics, treatment and advice in this area and justify the inclusion of speech therapy in the care of selectively mute people (Katz-Bernstein/Subellok 2009 and also Johnson/Wingens 2004). These pragmatic, communicative and narrative weaknesses have been identified in our approach to therapy. Another uncertainty lies in the differential diagnosis of mutism/profound developmental disorders (Autistic Spectrum) (see also Kramer 2006). The long years of experience and reports from parents in the newly formed self-help groups suggest accepting mixed forms of therapy. A glance at the literature points to the need for more research.
As already mentioned, any uncertainty in the development and acquisition of language, whether it be linguistic (on the semantic-lexical, phonological or on the syntactic-morphological level) or functional nature (on the phonetic level) or how it relates to performance in the language (on the pragmatic level), represents a risk factor for mutism (Spasaro/Schaefer 1999; Hartmann 1997; Bahr 1996; 2002; Schoor 2002). The following additional language disorders were found:
- Stuttering, cluttering (battarism)
- Partial/multiple dyslalia
- Dysarthrophonia, dysarthria, dyspraxia
- Severely limited vocabulary, semantic disorders
- Grammatical (syntactic and morphological) disorders
- Language impairment in bilingualism
If we see selective mutism as a potentiation of a number of factors which come together in this disorder, further risk factors are relevant.
Further risk factors:
- Bilingualism and migration (28% and 22%)
- Mental disorders, personality disorders of the parents (10.5%)
- Behaviour patterns resembling mutism amongst members of the family (72.2%, control group: 17.6%)
- Pre-, peri-, postnatal complications (75%)
- Disorders in pragmatic communicative competence
- Temperamental characteristics (withdrawal, shyness, timidity, silence) (Steinhausen/Juzi 1996, and references therein in Hartmann 2002)
- Sibling or twin family context (Subellok et al. 2011.)
This long list of findings confirms that mutism is a disorder which occurs in interaction with and in potentisation of other varied, disorders in children.
1.5 A Contribution to Aetiology: Why Are Children Silent? – The Failure to Overcome Unfamiliarity
„… a multi-dimensional model seems to be most appropriate for the explanation of SM“ (Steinhausen et al. 2006, 751).
„… in developmental psychology there is the assumption that a slight degree of stress makes development possible in a constructive sense: the demand on a child caused by a new experience, will lead to new skills and competencies if it can be overcome – by the child itself or by other persons. A demand triggered by extreme stress, however, causes a coping response, but not to coping. Nevertheless, the effects of the coping response are significant as far as development is concerned“ (Welzer 2002, 65).
In the literature, there are different explanations for the aetiology of (selective) mutism. Each particular explanation is usually clear from the research and therapeutic approach, the view of human beings as such, as well as the expertise and training of the authors themselves (Bahr 1996, 29). We can distinguish the following main types:
- Operant Conditioning
- Model-based learning and the experience of self-efficacy (Bandura 1977; 1983) (as in the learning theory approach)
- Neurotic behaviour as a result of a conflict which is expressed by silence; this is the psychoanalytic explanation (Lempp 1982; Kos-Robes 1976 etc.)
- Silence as a result of heredity or as a result of having a family as a model for a silent behaviour (Lebrun 1990; Black/Uhde 1995; Steinhausen/Adamek 1997;Cohan et al. 2006; Cunningham et al. 2006; Chavira et al. 2007) (genetic and systemic approach)
- Silence as a coping strategy (Bahr 1996)
- Silence as a symptom of an anxiety disorder (Yeganeh et al. 2003; Sharp et al. 2007; Carbone et al. 2010)
- Silence owing to multilingualism (Dahoun 1995; Elitzur/Perednik 2003; Yeganeh et al. 2003; Toppelberg et al. 2005;Kristensen/Oebeck 2007; Manassis et al. 2007; socio-linguistic approach)
The relevance of such ways of looking at the question is that they help educational and therapeutic professionals to work out the meaning of the mutism and thereby be able to take action (more on this, see Hartmann 1997, 71ff.; Bahr 1996, 28ff.). Each of these „viewing glasses“ allows further differentiation of the disorder and can relativise one's own and profit from the perspectives of others. Furthermore, therapeutic interventions can become better targeted and coordinated in an interdisciplinary sense.
In my opinion, one developmental-psychological aspect is important, deserving more detailed attention as a supplement to the papers by Hartmann (1997) and Bahr (1996) on the lack of communication and linguistic competence of the (selectively) mute child. This makes the transition between „familiar“ and „alien“ difficult. This perspective from recent developmental theories on infant and brain research is the basis for this book to examine and explain selective mutism (see Part II):
The rigid boundaries, which the child draws between „alien“ and „familiar“, prevent a social learning process. Development in childhood may be seen as an expanding area of „environmental snippets“ which the child can conquer through transitions (which can be susceptible to crises) (Bronfenbrenner 1980). The child is not able to make new acquaintances or to expand the radius of its movements and familiarity, either physically or mentally or in its construction of its autobiographical memory (Nelson 1993; Welzer 2002; Markowitsch/Welzer 2006). Thus, the child lacks the attractive contacts with teachers and peer groups which help to relativise the authority and the fantasised power and importance of the parents and to aid the gradual separation from them.
In order to cope with unfamiliarity, the child should be granted a number of factors:
- There must be a sufficiently stable attachment to the caregivers.
- Parents should be consulted in the selection and nature of new contacts. The child must be clear that befriending strangers is desirable in principle and that the loyalty of the parents is not (in principle) endangered by this.
- The child should already have had positive, non-threatening prior experience with strangers.
- It needs to know that it will be welcomed and (in principle) be liked in an unfamiliar place.
- Misbehaviour and failure at the new location must not have cruel and shameful consequences.
- The child should have internalised (greeting and leave-taking) gestures and rituals that symbolise the temporary nature of encounters and social rules which regulate intimate ...