Selective Mutism in Children

Part I
Theoretical Approaches

1 What is (Selective) Mutism?

1.1 Definition and Manifestation

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 2007).

"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 2007 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; Biesalski 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 2007, 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).

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 (Hartmann 2007, 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 Roth 2001; 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 (Kearney 2010). 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®" (Black/Uhde 1994; 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 et al. 2016).

What, then, is selective mutism? The following definition can be found in the ICD-10 (Dilling/Freyberger 2014, 331):

F94.0: Elective Mutism

This is characterised by a clear, emotionally induced selectivity of speech, so that the child speaks in some situations but not in other definable situations. This disorder is usually associated with particular personality traits such as social anxiety, withdrawal, sensitivity or resistance.

Related term: Selective Mutism

To be excluded:

■Transitory mutism as a part of separation anxiety disorder in young children (F93.0)

■Schizophrenia (F20)

■Profound developmental disorders (F84)

■Specific developmental disorders of speech and language (F80)

(According to Dilling/Freyberger 2014, 331: behavioural and emotional disorders with onset in childhood and adolescence)

In the literature, mutism is increasingly associated with anxiety and social phobias, (Overview in Smith/Sluckin 2015, 21) and currently also regarded as a complex disorder with multimodal diagnostics (Kearney/Rede 2021).

1.2 Diagnostic Criteria

"a.Persistent inability to speak in certain situations (where speaking is expected, for example, at school), although normal speaking ability is possible in other situations.

b.The disorder hinders educational or work-related performance or social communication.

c.The disorder lasts at least a month (and is not limited to the first month after starting school).

d.The disorder cannot be better explained by a speech disorder (such as stuttering), is not caused by a lack of knowledge of spoken language and does not occur in conjunction with autism spectrum disorders, schizophrenia or other psychotic disorders."

DSM-V (312, 23)

Frequent concomitant symptoms of Selective Mutism are social phobias and anxiety disorders.

Co-morbidities:

■Disorders of social behaviour, with oppositional behaviour

■Phobic disorders

■Other anxiety disorders

■Adjustment disorders in reaction to severe traumatic stresses

■Depressive symptoms

■Regulatory disorders relating to sleep, eating, and excretory functions

As mentioned in the DSM-IV, we often see children whose other language disorders are superimposed on mutism. As already mentioned, the state of research does not permit a linear, clear-cut aetiology. 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 2007; Bahr 2006; Dow et al. 1999; Schoor 2002; Spasaro/Schaefer 1999; Kristensen 2000; Manassis et al. 2007; Starke 2018).

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...