ACQ_Vol_11_no_3_2009

Mental health

Selective mutism or selective deafness? Debbie Plastow

Contemporary approaches to the management of children with selective mutism generally recommend various forms of behavioural intervention. Such approaches focus predominantly on the child’s symptom of not speaking. Nonetheless, the child does not exist in isolation. It is proposed in this paper that the child’s inability to speak in certain situations may be co-extensive with the difficulty of being heard by others. This may include the child’s family, teachers and even mental health professionals. An alternative treatment approach using psychoanalytic principles will be described in which the child’s symptom is considered in relation to the history of the family. The objective of this paper is to elaborate these notions through reference to a clinical case study. T he expertise of the speech pathologist in the assessment and treatment of children with selective mutism is becoming increasingly recognised in the psychiatric literature (Paul, 2007). The Diagnostic & Statistical Manual of Mental Disorders (4th ed.) [DSM-IV] criteria for diagnosis of selective mutism exclude a communication disorder (American Psychiatric Association, 2000), yet these children have an increased incidence of speech and language problems (Gidden, Ross, Sechler, & Becker, 1997). The speech pathologist therefore has a significant role in assisting with differential diagnosis, as well as in providing treatment in collaboration with mental health professionals (Gidden et al., 1997; Paul, 2007). In the field of speech pathology, most current approaches to the treatment of children with selective mutism advocate behavioural strategies, with specific goals outlined in graded stages with rewards for speaking (Gidden et al., 1997; Johnson & Wintgens, 2001). In such approaches, although the parents may be involved in aspects of the treatment, the focus is generally on the child’s symptom, that of not speaking. This paper will describe an alternative approach to the treatment of selective mutism, one which considers the child’s symptom in relation to the context of the family. Various treatments for selective mutism have been reported in the literature, including family systems, psychodynamic, pharmacological, and behavioural approaches (Stone,

Kratochwill, Sladezcek, & Serlin, 2002). However, according to Paul (2007, p. 427), “the most convincing literature pertains to behavioural modification approaches”. Stone et al. (2002) conducted a meta-analysis of the four most common approaches used in the treatment of selective mutism. It was concluded that behavioural approaches appeared to be effective in treating selective mutism, however further findings were limited due to insufficient quantifiable data in most of the studies. The authors recommended that future researchers adopt standardised measures and use a manualised treatment for consistency of approach. In their meta-analysis, Stone et al. (2002) noted that there was a paucity of information on family pathology in the children receiving behavioural interventions, suggesting that such frameworks do not give great significance to the family situation. Verhaeghe (2007) questioned the validity of such evidence- based methodologies in assessing the efficacy of most psycho- therapeutic treatments, and stated: “Instead of concluding that [evidence-based] methodology is too limited to [determine the effectiveness of psychotherapeutic treatments], the message is that those therapies that cannot be tested … are simply not scientific nor effective” (p. 5). Verhaeghe argued that the insistence on manualised or standardised approaches does not take into account the individual client or their social situation, including the place of the family. In this paper I would like to put forward that in a treatment that focuses predominantly on the behaviour of the child, the therapist unwittingly becomes aligned with the parents’ and teachers’ demand for the child to speak. In such approaches there may be the potential to bypass what lies behind the child’s silence, and the place of the parents in this. In other words, such treatments may overlook the particularity of the child and the family context. Family pathology is one aspect, but perhaps more important is the child’s symptom in relation to the family. What place, then, is there for the child to speak in his or her voice? In The Child, his “Illness” and the Others (1987), Maud Mannoni, French child psychoanalyst, wrote: “We find ourselves grappling with the history of a family … The child who is brought to us does not come alone, for he occupies a definite place in the fantasy of both parents” (p. 60). The history referred to concerns the spoken account that each of the parents gives of themselves and their child. Through this, the manner in which the child is caught up in the parents’ own wishes, aspirations, and ideals, becomes articulated. Consequently, the work undertaken with the parents can allow them to hear where they place the child in their own accounts. In this paper, a description will be given of my

Keywords CHILD SELECTIVE

This article has been peer- reviewed MUTISM SPEECH PATHOLOGY PSYCHOANALYSIS

Debbie Plastow

141

ACQ Volume 11, Number 3 2009

www.speechpathologyaustralia.org.au