CHAPTER 12
Approaches to Treatment of Selective Mutism in Other Languages
A case from Belgium
The following anonymized example shows how a child was helped within a very large Belgian school, without her parents having to exert pressure, because school staff were already familiar with the characteristics and needs of Selectively Mute (SM) children. Also, it appears to have been taken for granted that health and education staff would work together and include the family in any plans and that support would continue for as long as proved necessary.
A five-year-old trilingual, but SM, girl attended a Belgian school which has a proactive health policy. This meant that it has its own infirmary, approved health care workers including a contracted doctor, its own educational psychologist on the staff and, of course, Special Educational Needs Co-ordinators (SENCOs).
The school has 3000 pupils and uses 23 European languages, with many children becoming polyglot by the age of ten. However, it is accepted that children from minority language backgrounds, even in this unusually accepting environment, may be at risk for some delay in early language and that SM may increase that risk to some extent (Carmody 2000).
Several members of the girl’s family had spoken freely at home but not at school – indeed, the family had their own nickname for such children – but they had not previously heard anything about SM, and found the diagnosis immensely helpful. They had observed their child’s closed expression and protruding lower lip, but found the psychologist’s comparison – ‘a pressure cooker with the lid on’ – ‘a revelation’.
A letter about her diagnosis went to the school as well as to the family and the parents were advised to purchase Johnson and Wintgens (2001), which was described as ‘a manual for teachers’ and was in use as such with other children in the school.
After twice reading this book, the father constructed a detailed action plan with the school. This plan was granted ‘approved’ status, which meant that it was fully funded and was supported indefinitely by SENCOs, teachers and the school Director. Five years later, it is still in use to prepare for this child’s transition to senior school.
Some treatment approaches in Germany
The treatment of SM children in Germany is mainly the responsibility of speech and language therapists and psychotherapists. In order to qualify for free services under the parents’ insurance schemes, children have to be diagnosed by a medical doctor, who also has to recommend and oversee the treatment. This is usually of long duration, one to two years. Schools are involved in some regions, though not in all.
Mutism Self-help Germany
An organization founded, with Michael Lange, by specialist Speech Therapist Dr Boris Hartman is ‘Mutismus Selbsthilfe Deutschland e.v.’ (‘Mutism Self-help Germany e.v.’) www.mutismus.de, which both parents of SM children and SM adults can join (m.lange@mutismus.de) who organize meetings in different parts of Germany and sell very useful publications on the subject of SM (Hartman 1997, 2006; Hartman and Lange 2005). They also publish a journal Mutismus.de and maintain close contact with British and American groups.
See also Mutismus Selbsthilfe Schweiz www.mutismus.ch in Switzerland.
Selective Mutism in children: an integrative approach
Here follows an account of the treatment method used by Nitza Katz-Bernstein, a highly qualified SLT/Psychotherapist based at that time in Dortmund, Germany.
INTRODUCTION: WHY AN INTEGRATIVE APPROACH?
Selective Mutism is a complex disorder and has an interdisciplinary character. In Germany and Switzerland there are some therapy approaches that are more behavioural, more systemic or psychodynamic (Hartmann 2006; Kramer 2006). At our Clinical Centre for Speech Disorders at the University of Dortmund, we developed and established the ‘DortMut Approach’ that presents an integration of all three approaches.1 Our long-term experience showed that these children need specific approaches. The following factors indicate this:
•the complexity and interdisciplinary nature of the disorder between psychiatry, psychotherapy, speech therapy and special and/or integrative pedagogy
•the necessity of specific therapeutic media
•working with the (changing) resistance which is almost always present
•need for special handling of childish fears and ambivalence
•special concentration on speech therapy and language acquisition
•necessity to combine interactive and psychodynamic oriented approaches
•defining the work with parents and co-ordinating the work with other professionals.
The therapy approach that I present here has a targeted integration of methods. Neither a non-directive play-therapy which pays little attention to the symptom, nor a strict behavioural programme can claim better efficiency if used as the sole approach (Dow et al. 1999). The various approaches and methods will be explained here in an overview.
THERAPEUTIC INTERVENTION: SOME PRINCIPLES WHICH MAKE THE DIFFERENCE
The quality of a therapy does not rely only on techniques, but also on the quality of the professional relationship (Miller et al. 2008). I can summarize the qualities as creating a ‘holding professional frame’ within the therapy:
1.Promoting self-reliance
2.Responsiveness to intentions:
•assumption of a positive development
•proximal approach (always requiring something ‘in the zone of the next level of development’ (Vygotsky 1978)
•expanding tolerance of frustration
•humour, playing with paradoxes, playfulness provocation
•arousing motivation and curiosity
•consistent adherence to common, declared limits
•rituals, structure and demarcation of transitions
•negotiating decisions about progress together
•comfort and perseverance in the face of resignation, failure and errors, for example, ‘Was it too soon? Maybe it was the wrong boy to be the first to speak to? Ah, we weren’t paying attention. We must be more careful today!’
WITHIN THE THERAPY ROOM, MODULES OF INTERVENTION
HOW TO BUILD UP BASIC COMMUNICATION? NON-VERBAL STEPS
The ‘safe place’ is a therapy technique we use as a first step to build with the children, or, if not yet possible, to build for them a hiding corner, hut or tent, a so-called safe place within the therapy room while involving them in decisions about form, materials, size and so on, using the smallest bodily gestures or facial expressions to interpret their decisions. Usually they use the corner at the end of the first hour to hide, or hide the bear or the car they brought with them (Katz-Bernstein 2003, 2013), thus getting them to become involved and participate in a common interaction.
THE STRENGTHENING OF THE ‘ALTER EGO’
Encouragement is a main part of therapeutic work. It includes the acceptance of the silence as a coping skill that also has a positive aspect and, as such, is not going to be ‘taken away’ by the therapy. The declared goal is to widen the possibilities for the child to decide freely whether to talk or not and ask if he/she wants to give it a chance. Usually it evokes an acceptance toward the next steps suggested.
THE CONSTRUCTION OF A COMMUNICATIVE BEHAVIOURAL ABILITY
This is a directive, at first non-verbal type of therapy (see Katz-Bernstein 2003). It initially includes building up pragmatic skills such as eye contact and exchange of facial expressions as well as using gestures to point, describe and illustrate objects, positions and feelings. All of these are implanted in a playful interaction, such as making a ‘stop’ gesture within a game.
WORKING WITH PUPPETS AND TRANSITIONAL OBJECTS
This usually works with smaller children. At first the child is only asked to be an observer. The therapist is speaking to the shy tortoise or to the snail, both very shy toward the new child entering the room. The therapist gently introduces the child to the tortoise, encourages it not to hide. Usually such a puppet becomes the best therapy assistant, beloved as a social model in how to co-operate, talk, become cheeky, etc.
BUILDING LANGUAGE WITHOUT SPEAKING
These activities are mainly for speech clinicians, based on some principles of the symbolic play of Pellegrini (2009). An interactive view allows the development of an interaction with a narrative. The therapist suggests a play context to the silent child, such as a bus ride with a driver and a passenger, or a take-away restaurant. This way the child can be involved in the events and gently enter into an interaction, first as a silent role-taker, later in dialogue and further interactions.
SYMBOLIZATION AND NARRATIVE PROCESSING: NARRATION WITHOUT LANGUAGE
Being trained as a psychotherapist allows a widening of the narrative possibilities for an intervention. In the sand-box, or by taking roles, the child will often tell us some of his narratives, usually being pursued by his (own) demands for perfection, fears of failure or even by real events of being abused. A psychotherapist who knows how to work with ‘aggressive eruptions’ will thus be able to socialize and ‘tame’ the aggressions in a symbolic-narrative way.
THE FAIRYTALE BOOK WITH SPEECH BUBBLES: ‘HOWL, BOOM, SIGH…’
With school children, one child can play a wizard who can turn people into animals and then is asked to draw a picture of them interacting. Perhaps let them cut objects out of an old magazine – two that they like a lot and two which they find disgusting – while the therapist does the same; then they make a collage together. Once all objects are stuck down, the therapist suggests making some speech bubbles so these charcters can talk to each other, like comics. It seems to work as a transitional step to spoken words.
MODULES OF INTERVENTION: HOW TO BUILD UP SPEECH?
PRODUCING SOUNDS
As a first step with SM children, again, we are not talking yet but instead ‘investigating the sounds in the room’. Usually silent children avoid producing any sounds at all. I offer an exercise where the child follows me, walking and knocking on different objects. After a while we change roles and I follow him, discovering new sounds in the room. This way eye contact, turn-taking and being involved in a structured way of interaction is established (Katz-Bernstein 2003, 2013).
FIRST WORDS
The first words I invent are a natural and obvious necessity within an actual interaction. For example, playing ‘UNO’: ‘I think you can try and say UNO today! It makes it easier and is much more fun! I think it is going to work today.’ If it didn’t work, say: ‘Don’t let’s give up. We cannot expect it to work immediately; we will try it again next time!’ It is important for the therapist to stay supportive and encouraging. If it doesn’t work, give the child a break: ‘OK, today was the first try, often it takes time to get used to the idea / I am going to nag you next time / I hope that I don’t annoy you by being like that.’
WORKING WITH A RECORDING DEVICE
To speak required items on a recording device (voices of animals, music played by the child, a role-playing game in a Mickey-Mouse language, even reading or telling stories with bigger children) is one of the well-known, successful ways of starting to talk. To let the child record noises – strange imaginative language sometimes, while I am outside of the room – is a very helpful strategy for bringing speech into the therapy room.
SHADOW SPEAKING AND FORCED MOVES
Some of the children seem to be able to talk when there is a ‘shadow of noise’ around them: playing rhythm with loud drums, playing certain music, saying things in a chorus of voices, shifting in a role-play, imitating noises of animals, machines, traffic, and talking some words.
HOMEWORK AND TRANSFER: HIERARCHY OF PLACE, PEOPLE AND WAY OF SPEAKING
As a next step I refer to the decision to increase freedom of speech as a contract, which I promise to fulfil. I say: ‘Maybe it will be very easy for you and you will be astonished how it happens all by itself, or maybe it will not be so easy at the beginning, but we will just carry on.’ As a first step, I let the child do some ‘homework’: ‘You go to school and make a note of two teachers (children) you would like to speak to first and two of them you would like to be the last ones to talk with.’ I regard this step as seriously as speaking the first word, but it is still easy, so I encourage the child: ‘You see, you are doing well, the first step is done!’ As a next step the child should say the answer to one question at school silently to himself, imagining he is doing so aloud, practising the real step within the therapy room. Later on we are going to invite his best friend to practise further. Step by step, we will later be inviting the favourite teacher to visit and discuss next steps and arrangements. We are going forward, never giving up!
THE END OF THE THERAPY
Evaluation will be made by the child, parents and teacher as to whether they all think the child doesn’t need my support any more. A list of ‘What I have learned’, ‘What I still want to learn’, ‘Some wishes for the future’ and a celebration will signal the end of the therapy.
COOPERATION WITH FAMILY MEMBERS AND PROFESSIONALS
Working with parents of children, as well as the possibilities of working with teachers and social workers, medical and official professionals, is essential. This method, though, is child-centred, while the main goal is declared to be the widening of the communication skills of the child. The parents are usually not present in the room; they will be invited to attend special events – if the child so decides. That is the principle of the ‘safe place’.
We will help parents, though, around the actual problem and questions arising, to strengthen their parental presence: to be supportive towards the child as ‘the competent adult’. They learn to support their children to take some new steps and have some new experiences, in spite of their anxiety. Fear and anxiety are regarded as the old strategy that should be overcome (Lebowitz and Omer 2013) and the parents can learn to lose their own fear of the non-speaking behaviour of the child.
CONCLUSIONS
All these facets, techniques and suggestions are not meant to be seen here as additive and should not lead to a fragmented approach. The careful inclusion of both cognitive and emotional processes by the therapist ensures that the behavioural approach is founded on a psychodynamic, interactional and proximal approach. This is intended to help the individual components of the therapy to find a unifying and binding framework.
To summarize the approach above I will present four different approaches included in that concept for children with SM:
•sensitivity, empathy (psychodynamic approach)
•built-up co-operative actions (communicative approach)
•systematic training of communication and speech, transfer (behavioural approach)
•network (systemic approach).
All actions and approaches are based on resources and empowerment.
Current situation in Japan
We are grateful to Keiko Kakuta, representative of the Japanese Selective Mutism support group ‘Knet’ (abbreviation of ‘Kanmoku network’ – Selective Mutism Network with around 700 members) for producing this valuable account and to Kumi Andoh for translation.
Awareness of the needs of SM children seems to be at a fairly early stage in Japan. There is, as yet, little advice available for families, while school staff are not universally able to identify or respond sympathetically to children who fail to speak in class.
It was only around 2007 that the concepts of Special Needs Education and Individual Educational Needs started to be introduced into the Japanese educational system, so this should be taken into account, as well as other factors such as the school system and cultural background.
As teachers frequently deal with classes of 40 without assistance, it is difficult for them to do a great deal to help these most silent and least troublesome class members. In a normal class of a mainstream school, all are expected to perform in the same way, including pupils who may have some additional needs. Even though 6.5 per cent of children with a normal IQ showed noticeable academic and behavioural difficulties of various kinds in a government survey in 2012 (conducted by the Ministry of Education), 40 per cent of these children had never received any special educational support. This seems to indicate that services are in need of further development.
There are no official assessment systems for SM in Japan. Often, parents are informed by teachers or nursery nurses that the children are not talking. In many cases, they are just informed of their child’s silence in school, not the fact that they are suffering from SM. Even if they use the term ‘Selective Mutism’, parents are often given misleading information such as, ‘The child will grow out of it.’
By Japanese law, only doctors can perform a formal diagnosis. However, parents tend to seek advice from local organizations such as Child Consultation Centres and Child Development Support Centres, as well as having consultations with a school counsellor for school-age children. These centres give guidance and support for children’s development under the state system. Assessments are mainly performed by psychologists or speech and language therapists who belong to the organizations, and these professionals may not have enough knowledge of SM. They mainly assess children’s development by using IQ tests. Limitations are imposed by the practice of assessing only in the professionals’ own places of work and by the difficulty of conducting formal assessments with a child who is not comfortable talking.
Since these organizations are independent of the school system, it is difficult for parents to organize a support team co-ordinating teachers and other professionals. In Japan it would be difficult for a parent to become a key-worker in school, since it isn’t customary to have volunteers except for special activities. Although many schools provide a school counsellor or consulting services, the frequency and duration for each child doesn’t seem to be sufficient.
Problems are apt to arise at school from time to time, as there is an expectation that all children will actively contribute in front of their class to formal speaking events and ceremonies. This type of activity presents SM children with a frightening challenge and one which their teachers’ training does not equip them to recognize or ameliorate. Rather than teachers who express frustration and annoyance, SM children need teachers who will understand how to modify the demands of situations such as these.
Provision has been made in Japanese schools for intellectual impairment for a long time. Currently, there is provision for nine types of childhood special needs, including visual and hearing impairment, speech impairment, autism, emotional disorders and learning difficulties. Of these, SM is included in the category of emotional disorder. An SM child who has difficulties learning in a mainstream class might be enrolled in an SEN class or a short-term therapeutic institution for emotionally disturbed children.
For the last few years, some SM children have been able to attend special nurture groups known as ‘Tsukyu’ – held once or twice a week – with the aim of helping children to improve their social and academic performance. However, the provision of this service appears to be geographically uneven. School counsellors sometimes provide useful advice about not attempting to force SM children to speak, but there is little or no systematic behavioural treatment as there are currently very few professionals who practice Cognitive Behaviour Therapy (CBT) in Japan.
For the teachers themselves, there is no specific instruction or support around the topic of SM other than that provided by voluntary help groups or individuals, including Knet. Knet was formed by Keiko Kakuta, a specialist clinical psychologist, in 2007 – together with three parents of SM children. Through contact with Kumi Andoh, a well-informed learning support assistant, who undertook a good deal of translation, they made contact with SMIRA, whose handouts for professionals and for parents proved helpful. This network now has around 700 members and aims to tackle nationwide problems such as the shame and stigma surrounding SM, parental reluctance to ask for help, widespread misconceptions about the condition and lack of available treatment and training.
There is no SM specialist in Japan, although some research has been conducted since the 1960s. Although SM is commonly described as a rare condition with an incidence of 0.15–0.38 per cent in Japan (Kawai and Kawai 1994), the current true figure is unknown since a large-scale investigation has not been conducted in recent years. On top of this there are some problems with defining SM as there are confusions regarding judgement and co-existing disorders. It is noted by Keiko that some parents seem to be unaware of their children’s slight difficulties in speech, language and communication mainly because of certain aspects and characteristics of Japanese language and culture.
Recently a specialist paediatrician, Dr Kanehara, conducted a detailed investigation of aetiology (causes) and co-morbidity (associated problems) in 23 children with SM aged 3 to 14 years old who attended his clinic. He reported that the co-morbidity rate was very high – 60 per cent were reported to have developmental disorder, of which more than 50 per cent had an Autism Spectrum Disorder (Kanehara et al. 2009, pp.169–171). However, nearly 74 per cent of these SM children initially came for consultations on account of co-existing developmental problems rather than SM itself, which may possibly have had an influence on the findings. More research based on the general population of SM needs to be conducted.
Depending on the nature of co-existing problems, a combination of emotional support, psychological therapy and gradual, step-by-step behavioural guidance seems to produce good results. Research projects to examine treatment options are now needed.
In February 2013, a dramatized SM story based on Kirsty Heslewood (who later became Miss England) was broadcast on prime-time television. This was the first major feature on SM in Japan and it has created awareness amongst the general public. Also, there have been more mentions of SM in newspapers recently, as well as more talks and workshops in conferences on children’s developmental issues. This is due to the efforts by individuals and organizations such as Knet. We are hoping that these exposures and this awareness will lead to some kind of scheme in schools to deal with SM children in the near future.
Note
1Based on Katz-Bernstein (2013), www.fk-reha.tu-dortmund.de.