Selective Mutism in Children E-Book

Nitza Katz-Bernstein

• Herausgeber: Ernst Reinhardt Verlag
• Kategorie: Geisteswissenschaft
• Sprache: Deutsch

Seitenzahl: 481

Veröffentlichungsjahr: 2025

Beschreibung

Compact Basic KnowledgeWhy does the girl not speak in kindergarten? Why does the boy remain silent during school? Selectively mute children have the ability to speak, but choose not to use it in unfamiliar situations or in communication with certain people. A conversation with these children is often not possible at all or only via gestures or written messages. Nitza Katz-Bernstein elaborates in her book the symptoms of this dysfunction and explains the diagnostics and different therapies. She takes into consideration therapeutic elements from various disciplines such as speech therapy, as well as different schools of child and adolescent psychotherapy.

Leseprobe

Nitza Katz-Bernstein

Selective Mutism in Children

Manifestations, Diagnosis, Therapy

6th updated edition

With 2 illustrations and 6 tables

Translation into English by Terry Moston (3rd edition), updatededition by Harriet Rössger

Ernst Reinhardt Verlag München

Prof. Dr. Nitza Katz-Bernstein, Consultant, Supervisor, Child and Adolescent Psychotherapist (SPV, CH) and speech therapist, led the centre for counselling and therapy, and together with PD Dr. Katja Subellok the speech therapy clinic of the Faculty of Rehabilitation Sciences, University of Dortmund, Germany.

Note: Insofar as a dosage or administration of treatment is mentioned in this book, the reader may rest assured that the author has taken great care to ensure that this information corresponds to the state of knowledge at the completion of the work. The publisher cannot, however, guarantee information about dosage and application forms or other treatment recommendations. The use of brand names, trade names, trademarks, etc. in this publication, even without specific notation, does not imply that such names are not subject to trademark and trade protection laws or are deemed free to be used by anyone.

Bibliographic information published by the German National Library. The German National Library lists this publication in the German National Bibliography; detailed bibliographic data is available online through http://dnb.ddb.de

ISBN 978-3-497-62008-1 (PDF-E-Book)

ISBN 978-3-497-62025-8 (EPUB)

6th updated edition

© 2025 by Ernst Reinhardt, GmbH & Co KG, Verlag, Munich

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Cover design using photos of the Katz-Bernstein family, Bülach/Switzerland

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Content

A Brief History

Introduction

Part I Theoretical Approaches

1 What is (Selective) Mutism?

1.2 Diagnostic Criteria

1.3 Types of Mutism

1.4 Epidemiology, Co-Morbidity and Risk Factors

1.5 A Contribution to Aetiology: Why Are Children Silent?

The Failure to Overcome Unfamiliarity

2 Linguistic and Developmental-Psychological Approaches –

How Speaking and (Selective) Silence Develop

2.1 Why a Developmental-Psychological Approach?

2.2 Language Acquisition and Language Development –

Social-Interactive Position

2.2.1 Communication and Dialogue Structures –

How Is Communication Learned?

2.2.2 Triangular Processes –

Being Able to Deal with Requirements

2.2.3 Internal Mental Representation –

The Power of Imagination and Evaluation

2.2.4 Symbolisation and Narrative Organisation –

Acquisition of Narrative Skills

2.2.5 Separation of Internal and External Dialogue –

Conversation Strategies

2.2.6 Internalised Values –

Regulating Behaviour (= Mentalising)

2.3 Summary

Part II Diagnostics and Therapy Coordination

1 Diagnostic Surveys –

How Can (Selective) Mutism be Recorded?

2 Setting and Case Management –

Who, What, Where, When and What for?

3 Survey of Data Relevant to Therapy

Part III Therapeutic Approaches and Efficacious Treatments

1 Therapeutic Attitude

1.1 Exert Pressure or Use Laissez Faire? –

Planning the Therapeutic Relationship as a “Scaffolding” Principle

1.2 Relationship Design and Motivation

1.3 Models, Techniques, Training Programmes

1.4 Integrative Principles for Therapeutic Work

2 Therapy Planning

2.1 Clarification of the Tasks of the Treatment –

Dealing with Ambiguous Messages

2.2 Separation from Attachment Figures –

Mum Waits Outside!

2.3 Safe Place –

The Safe Place as a Starting Point

2.4 Strengthening the “Alter Ego” –

“Prove to Me that I’m Okay the Way I Am!”

2.5 Perseverance –

Working without Response

Part IV Communicating Non-Verbally

1 Constructing Communicative Behaviour –

“Turn-taking”

2 Working with Puppets and Transitional Objects –

A Hut for the Bear

3 The Fairytale Book with Speech Bubbles –

“Howl, Boom, Sigh …”

4 Language Therapies –

Building Language without Speaking

5 Symbolisation and Narrative Processing –

Narration without Language

5.1 The Symbolic Game as Therapeutic Intervention

5.2 The Relevance of Symbolic Play in Therapy

5.3 The Therapeutic Role in Symbolic Play

5.4 Digression: Developmental Diagnosis of Symbolic Play

6 Taming Aggression in Symbolic and Role-Play

Part V Building Verbal Communication

1 Communicating with Sounds

2 First Words

2.1 The First Word of the Preschool Child –

The Art of Making Assumptions

2.2 The First Word of the Schoolchild –

Hierarchy of Place, People and Way of Speaking

3 Working with the Tape

4 Shadow Speaking and Forced Moves

5 Working with “Ego-States”, “Inner Voices” or “Introjects”

6 Homework

7 Transfer: The Generalisation of Speaking Ability

8 Crisis and Resistance

9 The End of the Therapy: Evaluation and Departure

Part VI Cooperation with Relatives and Experts

1 Family and Silence

2 Cooperation with Parents and Relatives

2.1 Principles for Working with Parents

2.2 Special Aspects of Working Together

2.3 Issues of Frequent Concern to Parents

2.3.1 Dealing with Temper Tantrums and Aggressive Behaviour of the Child

2.3.2 Advice Regarding Use of Medication

2.3.3 If Violence or Abuse is Suspected

3 Mutism and School

4 Cooperation with Other Professionals

Part VII Case Report

Lui, the Class and I

Finding a Way out of Silence Together by Ruth Marosi

The First Week of School

Second Grade

Third Grade

Addendum 1

Addendum 2

Addendum 2

Summary of the Case Studies

Bibliography

Index

A Brief History

When I gave up my therapeutic work after 22 years in order to work at the University of Dortmund in Germany, I made a promise to myself to write a book on the therapy of (selectively) mute children. Working with them so impressed, influenced and fascinated me that I wanted to share the experience. The work in Dortmund made great demands on my time and energy. Apart from the routine of the university, the speech therapeutic clinic changed location and the new, modular diploma course “Education and rehabilitation in disorders of language, communication and hearing” had to be established. Through cooperation with other countries new research and projects came about.

From the start of my work as director of the out-patients facility for speech therapy, the dream of establishing a drop-in centre for children with (selective) mutism pursued me. I knew that there were not enough informed and specialised agencies for these children. I also knew how demanding and intensive the treatment of children is as well as the work with families and therapists.

Several surveys by trainee teachers on the prevalence of mutism in state schools in North Rhine-Westphalia gave this topic new impetus. The need for information and treatment was evident. As a result, we held an information event for professionals and affected parents in the outpatient clinic for speech therapy at the University of Dortmund. The first targeted requests about information and treatment began to reach us. The time was ripe, staff who were motivated and trained were there, and so the Mutism Network was set up at the clinic. Today, the Speech Therapy Clinic of the University of Dortmund can look back over therapeutic and counselling work in over 400 cases of selective mutism in children and adolescents, as well as intensive research activity, dating back to 2019. Many of the therapeutic elements that are described in this book were taught during training and supervision to the relevant therapists and this will now feed into the practical work with the children. The concept was developed further and “DortMuT” came into being.

When I told a school psychologist about the book I was in course of writing, she told me enthusiastically about a teacher who had succeeded in teaching a child with selective mutism in her class to talk through pedagogically skilful interventions. I wanted to include this report in my book, as it strongly supported my interdisciplinary approach in relation to mutism and showed that skilful use of educational measures can achieve results. Over the years, this interdisciplinarity has become a hallmark of the therapeutic approach. The report by Mrs Marosi is appended at the end of this book. At this point I would like to thank Mrs Marosi warmly. And very special thanks must go to PD Dr. Katja Subellok, Director of the Outpatient Clinic, Kerstin Bahrfeck-Wichitill, Prof. Dr. Anja Starke and the entire team, who continue to work with selectively mute children and adolescents in research, teaching, therapy and counselling with commitment and enthusiasm in my absence, as I have now been retired for over fifteen years.

Since 2005, the year of the first edition of this book, much has been done in the field of selective mutism. A current topic in research relates to the question as to whether selective mutism can be regarded as a phenomenon that can be included in the group of social phobias or anxiety disorders. For this purpose, in the present sixth edition, current literature sources are included. There is also active international research which takes up issues of co-morbidity, the differential diagnosis of familial and cultural background in selective mutism (Starke 2018). Also noteworthy are the contributions by Katja Subellok and Anja Starke, who have co-edited two specialist journals on the topic (2017). Current research and publications confirm and even consolidate the complexity and co-morbidity of the disorder. Additionally, reliance on methodological diversity and interdisciplinarity has intensified (Melfsen et al. 2021, Kearney/Rede 2021, Florineth-Baatsch et al. 2024).

The therapeutic intention put forward here to involve children with selective mutism in activities, roles and interactions is reinforced by older and more recent language acquisition theories as proposed by Eisen (1993), Tomasello (2009; 2010; 2020) and Pellegrini (2009; 2010) and in German-speaking countries by Andresen (2002; 2005).

Moreover, I am delighted that the 6th edition of this book is also available in English, making the work accessible to other linguistic regions.

Important discoveries clearly demonstrate the developmental risk of children with selective mutism and confirm the use of speech therapy as an appropriate discipline, as well as the interdisciplinary and integrated approach which we have been practicing as a team in the speech therapy outpatient clinic of the University of Dortmund since 1995. We have recently christened this approach DortMuT – Dortmund Mutism Therapy (Subellok et al. 2011). In our book based on case studies “Find courage to speak” (Katz-Bernstein et al. 2021) this interdisciplinary approach is concretised.

At the outpatient clinic at the University of Dortmund, which has been under the overall leadership of PD Dr. Katja Subellok since my retirement, the Mutism Network for Research, Education and Treatment has been greatly expanded and firmly established under the direction of Kerstin Bahrfeck-Wichitill.

Among experts, too, with whom we in Dortmund are in close contact, gratifying developments have occurred; study sites are increasingly integrating selective mutism in their programmes and study centres and surgeries are interlocking in research and training activities. In addition, a significant quantity of literature has recently been published in German (Brand 2009; Garbani-Ballnik 2009; Hartmann 2019, among others), and a new specialist journal “Mutismus.de” for therapy, research and self-help from Mutismus Selbsthilfe Deutschland e. V. (www.mutismus.de) is being published under the direction of B. Hartmann and M. Lange. The advocacy group IG-Mutismus (available at www.mutismus.ch, under the direction of Sandra Melliger and Beat Schweizer) has also become well established in Switzerland. Further overviews of different countries in the booklet mutismus.de, 2014/6 are also available. All these developments contribute to gathering new experiences and anchor selective mutism in the sphere of speech therapy in accordance with international efforts to develop it as a vital discipline in addition to psychotherapy and psychiatry (for an overview, see Cleator 2015).

A final remark: the literature of factors in psychotherapy, with which I have been working intensively in recent years, can confirm in a fascinating way my long-time therapeutic expertise and the developmental and language acquisition theories which I advocate. I have therefore inserted at the beginning of certain chapters quotes from the literature on such current factors in order to make clear the relationship with selective mutism and to link it with therapeutic experience (see also the survey on factors in psychotherapy, Florineth-Baatsch et al. 2024).

Zurich, May 2023

Nitza Katz-Bernstein

Introduction

The aim of this book is to provide general information on (selective) mutism in children. Its main concern, however, is to offer suggestions about diverse, specific therapeutic and rehabilitative approaches and tools to teachers and therapists from different fields who work therapeutically with (selectively) mute children of different ages or teach or supervise them. It explains therapeutic components, processes and specifics related to children’s disorders. Therapy and support can be adjusted depending on individual needs and indications of the child, according to the acquired competences, capabilities and responsibilities of the psychotherapist, the speech and language therapist and also the teacher who is responsible for the child.

For therapists with more experience, the book can enable an extension of their personal approaches or offer a confirmation, a deepening and/or systematisation of their interventions. For as Hartmann (2007), Bahr (2015; 2016), Schoor (2002) and Kearney and Rede (2021) emphasise, collections of case studies and individual documentation for this disorder are particularly important and valuable. Only they can concretise therapeutic procedure and help to overcome helplessness, regression and stagnation which are in the nature of the course of therapy with these children (see also Florineth-Baatsch et al. 2024).

Years of practical experience which are evidenced in this book as well as supervisory support and advice by therapists and teachers show how crisis-prone and fragile working with these children can be in their therapeutic and educational efforts. As a result, reliable information as well as professional support and assistance are indispensable, at least where there has been little experience in working with (selectively) mute children. This book aims to provide a building block of such expert support.

In addition, this book will offer an example of integrative approaches independently of any doctrinal dispute and any different fields of expertise (as defined by Miller et al. 2000; Metzmacher et al. 1996; Wampold et al. 2018; Schwarz/Fink 2019; Flückiger et al. 2020). (Selective) Mutism as a concrete disorder in childhood demands action where the need for integration and interdisciplinarity is clear owing to its diversity and complexity.

My long-term therapeutic and supervisory work with children with (selective) mutism has increased my conviction that these children need specific approaches. The following factors indicate this.

1.The co-morbidity, complexity and thus interdisciplinary nature of the disorder

2. Placing of therapeutic measures between psychiatry, psychotherapy, speech therapy, special and/or integrative pedagogy

3. The need to take account of different theoretical approaches for therapy

4. Necessity of specific therapeutic media

5. Working with the resistance which is almost always present

6. Special handling of fear disorders and ambivalence within the child

7. Special concentration on speech therapy and language acquisition with non-speaking children

8. Necessity of “ideographic”, interactive, psychodynamic and behaviour-modifying approaches

9. Defining and delimiting the work with parents and families, assisting in a change of environment, at children’s care homes or as inpatients.

1. The co-morbidity, complexity and thus interdisciplinary nature of the disorder: (Selective) Mutism is located at the intersection of a number of fields: medicine, child and adolescent psychiatry, psychotherapy, speech and communication therapy, pedagogy, special needs education, social education and social work (Hartmann 2007; Sharkey/McNicholas 2008). The respective decision as to which therapeutic, educational, and/or psychiatric interventions should be chosen and how these should be concretised and linked requires a coordinated case management. The absence of such management significantly reduces the chances for successful treatment and rehabilitation, which are of great importance for achieving prevention before puberty (Melfsen/Walitza 2017; Melfsen et al. 2021; Schwenk/Gensthaler 2017).

2. Placing of the therapeutic measures between the fields of psychotherapy, speech therapy, special and/or integrative teaching: One of the difficulties in the planning of therapy lies in the distinction between the disciplines which need to be selected as rehabilitative and therapeutic measures. The psychiatrist for children and adolescents, who is presented with a (selectively) mute child, is obliged to cooperate with different experts. In a further step, the doctor has to know whether a therapist trusts himself/herself to work with the (selectively) mute child and its family and if s/he is willing to take on responsibility. In addition, there is the difficulty of the diagnosis. A diagnosis is necessary at the start of therapy with a psychotherapist to determine the status of the development of speech and/or language comprehension by asking the parents and/or using recordings from home. An accurate diagnosis and differentiation of the disorder is usually difficult and often requires involving a speech therapist. Therefore, in order to diagnose an additional language delay and/or a different language disorder besides the (selective) mutism, which, according to different sources, may often be the case (Rösler 1981; Lempp 1982; Kristensen 2000; Cunningham 2004; McInnes 2004; Manassis et al. 2007; Sharkey /McNicholas 2008), including the aspect of speech therapy during psychotherapy is essential.

The speech therapist, however, is faced with mental and developmental characteristics and peculiarities, which s/he rarely meets in this magnitude and severity. The systemic work, i.e. the inclusion of parents, educators and teachers, presents the speech therapist with special transdisciplinary demands. If necessary, s/he must pass on the counselling work with parents (see Katz-Bernstein/Subellok 2009; Subellok et al. 2012; Florineth-Baatsch et al. 2024).).

In order to best encourage and support a (selectively) mute child at school, the relevant education authorities and teachers have to rely on the aforementioned psychological and speech therapy diagnosis. Without active and concerted cooperation with teachers, it is inconceivable to address or generalise the symptom or those communicative and linguistic behaviour patterns which manifest themselves. Therefore, the mutual exchange of information and in particular the coordination of ongoing interventions and the acquisition of specialised knowledge from other disciplines are unavoidable. A recent publication from the U.S. illustrates the expansion of opportunities in the education of these children (Kearney 2010; Kearney/Rede 2021).

3. Necessary consideration of different theoretical approaches to therapeutic methods: Unlike many other disorders, the treatment of children with (selective) mutism needs to include different modules in order to be successful (Katz-Bernstein 2002, Part III–VI of this book). Regardless of professional responsibilities, various possible levels of treatment should be presented so that the decisions for normal therapeutic and educational routines and support measures can be carried out more efficiently.

This book aims to offer integrated therapeutic blocks taken both from the different schools of psychotherapy, as well as various disciplines of child and adolescent psychotherapy and speech therapy/speech-orthopedagogy. Nowadays such integration finds widespread support in the light of research into psychotherapeutic factors (Miller et al. 2000; Wampold et al. 2018). This should not be understood as a plea for a return to short-term therapies, since no scientific superiority over other methods in terms of time resources could be detected in favour of these modern therapies (Miller et al. 2000, 24). For the therapy of (selectively) mute children it is to be hoped that they can meet the demand for ever shorter interventions.

Rather, this book aims at achieving a high efficiency of therapy through different approaches and a targeted integration of methods.

The procedural gathering of diagnostic data includes both data from observations in the classroom, as well as those which are collected by school medical services and professionals in educational psychology, psychotherapy or speech therapy.

Case management can be implemented in an interdisciplinary team. Clarifying the treatment, establishing methods for achieving a relationship and communication contains elements from systemic-oriented psychotherapy. However, this is built into a process-oriented set of dialogues and thereby gains a base in depth psychology.

The Safe Place is a therapy technique that is based on the concept of the “Safe Place” which comes from a practice popularised by Violett Oaklander (1981), supported by the theory of intermediate space of Winnicott (2002) and was developed as a blueprint for the work with severely traumatised patients (Reddemann 2017; Tinker/Wilson 2006). The concept of “Safe Place” was used for anxious, mute children and/or children with language disorders and elaborated praxeologically for Integrative Child Psychotherapy (Katz-Bernstein 1996; Melfsen et al. 2021).

The strengthening of the “Alter Ego” is borrowed from Adler’s individual psychology (Adler 1974) which considered “encouragement” as an important part of therapeutic work.

The construction of a communicative behavioural ability is a directive, but non-verbal type of therapy, and has been tested for many years in speech therapy work with children suffering from language delay (Franke 1996) or with stuttering (Katz-Bernstein 1982; 2003b).

Working with puppets and transitional objects (Petzold 1983; Tarr Kruger 1995) is based on ‘Integrative Therapy’ and was developed for psychotherapeutic work with children and young people (Petzold/Ramin 1991). The new game theories confirm its efficiency (Pellegrini 2010). It can be used especially for preschool age children and ones at the lower primary school level.

The speech therapy measures are derived from the work with children with delayed speech development. A psychodynamic view of the psychotherapy of children and adolescents allows the inclusion of the level of symbolism and the use of narrative (Schröder et al. 2014; Katz-Bernstein/Schröder 2017). In this way, the therapist can suggest themes central to the silent child through the use of symbols, intervene psychodynamically in the events and gently enter into an interaction in dialogue with the child.

Building verbal communication (including transfer), which subsumes the symptom step by step, comes from cognitive-behavioural-based therapeutic approaches and uses for example the creation of hierarchies of speech and silence, desensitising exercises, etc.

Working with inner voices is a technique taken from Gestalt therapy (Perls 2002; Watkins/Watkins 2003). Working with ego-states was developed mainly for people with traumatic experiences (Fritzsche/Hartmann 2010). Through the use of creative media, this kind of technique can be used in therapeutic work with (selectively) mute children and adolescents, in an age-appropriate and playful way.

The work of the Guided Imagination is a technique by Leuner, known as “catathymic imaginative picture experience” (Leuner 1986). It is used in the systemic-oriented hypnotherapy with children (Mrochen 2001) and in Integrative Child and Adolescent Psychotherapy (Katz-Bernstein 2003b).

Cooperation with family members and professionals is derived in turn from systemic-oriented strategies and shows both ideas and peculiarities in working with parents of mute children, as well as the possibilities of working with teachers and social workers, medical and official professionals (see Katz-Bernstein 2010b; Subellok/Katz-Bernstein 2006).

Other ideas and suggestions come from our many years of working with children as well as supervisory work which all gave me insight into hundreds of therapies. They arose during the search for ways to gain access to difficult-to-reach children. Many of these suggestions have been jointly developed within supervision groups that I led for many years in many countries and with many different cultures. The supervision groups had as their main focus child and adolescent psychotherapy, language and speech therapy and movement and music therapy.

All these facets, techniques and suggestions are not meant to be seen here as additive and should not lead to a mechanistic, fragmented approach. The careful inclusion of cognitive, behavioural and emotional processes by the therapist ensures that the work is well-founded from a psychodynamic perspective. This is intended to help the individual components of the therapy find a unifying and binding framework.

4. Use of special therapeutic media: Working with a child that refuses to speak is a challenge that both psychotherapists as well as speech therapists often (still) find unusual. Looking at case studies can help the reader better understand the use of special media and techniques.

5. Specific work with the resistance which is almost always present: A therapist working with (selectively) mute children, is often in difficult states of mind which arise from the resonance (“countertransference”) coming from the resistance and refusal apparent in the body language which the child communicates. In order to identify and understand these patterns of interaction and these processes, special therapeutic qualities are necessary which are largely learnable. Through literature, case studies and supervision, a sensitivity for dealing with these communication patterns can be developed. I consider the inclusion of this level in dealing with mute children as indispensable.

6. Knowing how to deal with fears and ambivalences within the child: (Selective) Mutism is also described as anxiety disorder in the existing literature (Spasaro/Schaefer 1999) or as a symptom of its co-morbidity (DIMDI 2014; DSM 2013; Muris/Ollendick 2015; Chavira et al. 2007; Cunningham et al. 2006; Gensthaler et al. 2016; Kearney 2010; Kristensen 2000; Manassis et al. 2007; Melfsen/Walitza 2017; Melfsen et al. 2021; Steinhausen et al. 2006; Vecchio/Kearney 2005; Yeganeh et al. 2003). Dealing with anxiety disorders requires therapeutic knowledge and also special forms of didactic approaches in therapy. There is always an ambivalence between the wanting to be free of the symptom and the wanting to remain within familiar behaviour patterns. This routine, familiar behaviour is in fact a fear-management strategy, a solution for demands on the child’s development which the child does not know how to solve differently (Perednik 2011). Through detailed case vignettes and examples, a number of possibilities for therapeutically dealing with fears and ambivalences inherent in the nature of this phenomenon emerge.

7. Special concentration on speech therapy and language acquisition with non-speaking children: Language deficits, delays in speech development and disorders, which, as research shows again and again, are often concealed behind mute behaviour (Bar-Haim et al. 2004; Cohan et al. 2006; Kearney 2010), require a specialisation which has similarities to the work with non-speaking persons (AAC – Alternative Augmentative Communication). However, unlike the work with non-speaking persons with severe physical or cognitive limitations, speech therapy work with mute children requires its own special character and a particular didactical form of therapy which will be discussed in this book and presented as a possible model.

Mention should be made of determining the degree and extent of language comprehension, of passive (and active) vocabulary, the level of syntactic-morphological development, fluency and articulation. Likewise, the ability to symbolise and narrate need to be checked. This “diagnosis under prolonged severe conditions” is necessary to determine the nature and extent of the disruption and to coordinate therapeutic interventions amongst the different experts.

Every delay and disruption in language development can be a primary or secondary potentiating factor for this disorder (see Kearney 2010). If a linguistic abnormality is identified, support in language acquisition can be an important element in overcoming mutism. In the course of such support in communication, symbolisation and language development, little response can be expected at first and it is conducted initially in a “void”. It therefore requires a non-directive sort of language development, which is associated with other components of the therapy.

8. On the necessity of “ideographic”, integrative, cognitive-behavioural,interactive and psychodynamically oriented approaches: (Selective) Mutism is constantly changing because of objective external factors, because of internal, developmental progression and the interaction between these. Therefore, an “idiographic” (Motsch 1992), individual case-oriented approach (Grohnfeldt 1996, also Petermann 1996) is almost inevitable. This requires the inclusion of quantifying, objectifying criteria which must be brought to bear on establishing criteria and procedures of a qualifying nature. This may mean that an on-going critical examination and continuous adaptation of the treatment plan must be made. In most cases it makes sense to pursue a plan which can be readily adapted and changed. In order to distinguish, for example, whether a flexible change of method or whether persistence and perseverance using one particular method is therapeutically more useful, it requires case-specific insights into individual case histories that illustrate a differentiated approach and reflect themselves in how the relationship of the therapy is designed (see Katz-Bernstein 2008; Bennett et al. 2013; Bergmann et al. 2013; Kristensen/Oerbeck 2013).

9. Choosing forms of working with or delimiting work with parents and families, helping during a change of environment, starting a stay in a children’s home or in-patient care: Taking into account family members and the systemic dimension are essential in treating this disorder (Chavira et al. 2007; Kristkeitz 2011).

The failed social transition of the child from the parental home to the social context of the kindergarten and/or school can rarely be overcome without the support of the parents and the involvement of the teachers. If this circumstance applies to most psychologically related disorders as well as to speech disorders, the specificity and complexity of (selective) mutism and its serious consequences demand special attention to the family (Katz-Bernstein 1993; 2000; Katz-Bernstein/Subellok 2009; Florineth-Baatsch et al. 2024). In an ideal case, successful cooperation can influence the therapy in a significantly positive manner.

Some parents of mute children find it difficult to support the treatment of the child by working with the therapist. These parents require time and patience on the part of the therapist. Therapists should sometimes expect, in addition to the good cooperation with motivated and concerned parents, also having to be content with minimal cooperation in some cases and yet still be willing to devote themselves fully to the child. Some parents will be encouraged to participate by unexpected progress of the child.

The risk of disappointment in working with families of (selectively) mute children is considerable when compared to interventions in idealised, systemic families which is the basis for many systemically oriented concepts. Often the parents belong to a different culture or social class in which it can be the case that the way the problem and its meaning are allotted have a different relevance than the public institutional norm. It is also possible that the parents speak the language poorly. This can affect the attitude to therapy or lead to misunderstandings and mutual suspicion as to expectations and agreements. There are also issues of support measures at school, of clarifying the choice of the appropriate local places of support and, in rare cases, institutionalisation or hospitalisation of the child, to be agreed with the families. Above all, we concentrate on child-centred cooperation alongside the therapy (Katz-Bernstein 2000; Subellok/Katz-Bernstein 2006). This type of collaboration seems the most common, often the only possible and feasible way to deal with the parents.

As already mentioned, both the behaviour-modifying as well as the interactive, psychodynamic dimensions have been considered in this book. Taking a serious approach to the psychodynamic strategies communicated by body language belongs to the integrative, therapeutic view that is presented here (Katz-Bernstein et al. 2002). The inclusion of these strategies is demanding and not always easy, requires training and experience in order not to remain additive but to become fully integrative. It is nevertheless, in my opinion, trainable. For the treatment of (selectively) mute children such a combination seems to me to be useful and appropriate in most cases. It would be a loss if a loyalty to certain “psychotherapeutic ideologies” were to distort the view of how to gain access to these children (Miller et al. 2000; Fiedler 2000; Schwarz/Fink 2019).

Part ITheoretical 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 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 comorbidity 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 1992) 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 aetiology. 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:

■Initial mutism

■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 paediatrics 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 2006, 37ff; Hartmann 2007, 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 aetiology 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 2006, 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 the Mutism Network: www.fk-reha.tu-dortmund.de/zbt/de/spa/mutismus/index.html, more recently also the IMF – Interdisziplinäres Mutismus Forum). 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 the self-help groups Selbsthilfe Mutismus Deutschland e.V. (www.mutismus.de), StillLeben e.V. (www.selektiver-mutismus.de) and IG Mutismus Schweiz (www.mutismus.ch). In recent years, a lively professional exchange as well as further training and counselling activities in German-speaking countries have been conducted. This also includes the newly founded journal ‘Mutismus.de’ (for other countries, see Smith/Sluckin 2015, 289f).

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. Steinhausen describes as mute 0.5% of children with psychiatric abnormalities (Steinhausen 2000, Steinhausen et al. 2006; 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; further current sources: Capozzi et al. 2017; Gensthaler et al. 2016). Other sources, however, refute this trend (Hartmann 2007, 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 2007, Kristensen 2000; Bar-Haim et al. 2004; Henkin/Bar-Haim 2015; Manassis et al. 2007 and others).

Castell/Schmidt (2003, 2) name the following comorbid psychiatric side effects:

■Social anxiety

■Disorders of social behaviour, 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:

Psychopathological disorders

■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 (onychophagia), 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%)

Developmental disorders

■Statomotor developmental delay (31.3%)

■Speech delay (65.6%)

■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).

Further “characteristics” can be found in the Anglo-American literature:

■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

■Trauma

■Global severity in parents

■Fear of strangers (xenophobia)

■Depression

■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; overview in Kearney 2010; Smith/Sluckin 2015). Selective mutism is now categorised as an anxiety disorder (Capozzi et al. 2017; Gensthaler et al. 2016; Melfsen/Walitza 2017).

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) or impairment of other basic skills are linked to language development, such as auditory attention span (Bar-Haim et al. 2004; Henkin/Bar-Haim 2015). Selective mutism also occurs together with linguistic uncertainty due to migration (Elitzur/Perednik 2003; Kristensen/Oerbeck 2006; Manassis et al. 2007; Toppelberg et al. 2005; Yeganeh et al. 2003, Starke 2018). 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, Cleator 2015). 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; Katz-Bernstein/Subellok 2009; Melfsen/Walitza 2017). 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)

■Global severity in parents (Capozzi et al. 2017)

This long list of findings confirms that mutism is a disorder which occurs in interaction with other varied, disorders in children, which may be compounded in consequence. An interdisciplinary approach is therefore justified.

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 2006, 29). We can distinguish the following main types:

■Operant Conditioning

■Model-based learning and the experience of self-efficacy (Bandura 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 2006)

■Silence as a symptom of an anxiety disorder (Yeganeh et al. 2003; Sharp et al. 2007; Carbone et al. 2010; Capozzi et al. 2017)

■Silence owing to multilingualism (Dahoun 1995; Elitzur/Perednik 2003; Yeganeh et al. 2003; Toppelberg et al. 2005; Kristensen/Oerbeck 2007; Manassis et al. 2007; Starke 2018)

■Diathesis Stress Model (Cohan et al. 2006; Hartmann 1997)

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 2007, 71ff; Bahr 2006, 28ff). Each of these “viewing glasses” allows a further fruitful relativisation. 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 (2007) and Bahr (2006) 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.

■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 and more distant on-going relationships.

■A certain measure of regulation of relations by the child itself should be ensured.

■The child should have sufficient fearlessness, relaxation and curiosity to take part in communicative games and interactions that arise from mutual adaptation and common creativity.

■It needs sufficient linguistic competence to understand instructions, announcements and aids to orientation, to articulate urgent needs, asking for help and communicating intentions. It should be able to understand stories and reports and show interest, expressed through typical listening behaviour (Schröder et al. 2014).

■Finally, the child should have narrative and expressive skills to talk about itself and others, to think and develop its own autobiographical construct (Andresen 2002, 2005; Fujiki et al. 1997; McInnes 2004; Quasthoff et al. 2011; Schröder et al. 2014; Katz-Bernstein/Schröder 2017).