德國「選擇性緘默症處理十個準則」

2013年6月8日，在德國斯圖嘉特(Stuttgart)召開的第11屆選擇性緘默症年度大會，通過了「選擇性緘默症處理十個準則」(Stuttgarter Rahmenempfehlungen zur Mitismus-Therapie, SRMT)。

1. 所有緘默症治療的目標，是開啟口語溝通和心理社會能力，使說話不受限於情境和對象。
2. 處理溝通障礙的緘默症，可能包括精神、心理、口語和語言/口咽，以及運動等治療，需視個別病理狀況而跨科別的合作。
3. 緘默症治療應包括核心家庭系統，固定進行家長諮商，以去除家人強化緘默行為的因素。
4. 為確保說話從治療情境轉移至日常生活，需和緘默者的機構環境(幼稚園、學校、實習公司、政府兒少福利機構、職業中心、受雇場所)密切合作。
5. 較佳的緘默症治療是引導、口語方式，以一開始就「說話」為起點，避免形成不說話的習慣模式。建議的治療頻率是，彈性分配每星期共兩小時。
6. 非引導、非口語治療方式，若在一年內無法讓緘默者在治療或非家庭情境說話，則應該拒絕。因為它會鼓勵緘默病程的延續和慢性化，並且強化緘默帶來的主觀好處。
7. 有效的療程應在24次以內開啟口語溝通和引導出第一次說話。
8. 在教育情境中，應該避免讓緘默者免除口語評量和接受課堂協助。因為兩者都會助長緘默的延續和慢性化，並且可能導致合併的病理症狀(認知和語言應用表現缺陷、合併行為障礙)。
9. 由於自幼年起，緘默症便可能伴隨其他心理疾病，因此需要進行社交恐懼症、憂鬱症和強迫症的(非口語)評估，青少年和成人的治療亦應考慮合併症。
10. 在治療特別難以奏效的個案中，應考慮輔助性的藥物治療。緘默症的文獻推薦一組稱為「選擇性血清素回收抑制劑」(SSRI)的活躍物質。藥物應納入整體治療計畫中的一環。

資料來源： p.10 Mutism International《Mutismus.de》Oktober 2014。

英文版：
Stuttgart Guidelines for the Treatment of Selective Mutism

1. The goal of every mutism therapy is the verbal communicative and psychosocial opening of the mutism and thus speech, independent of situation and person.
2. For the treatment of the communication disorder mutism, psychiatric, psychological, speech and language therapeutic/logopedic and ergotherapeutic approaches are a possibility. Mutism requires, depending on the individual pathology, an interdisciplinary cooperation.
3. Mutism therapy should include the system of the nuclear family through a consistent parent counselling in order to eliminate factors in which relatives maintain the mutism.
4. In order to guarantee a transfer of speaking from the therapeutic setting into everyday life, a close cooperation with the institutional environment of the affected persons (kindergarden, school, apprenticing company, government office for youth welfare, job center, place of employment) is necessary.
5. Fot the treatment of mutism, directive, verbal treatment approaches that start with "speaking" from the beginning are to be preferred in order to avoid adaption effects of non-speaking among the affected persons. As an ambulatory therapy frequency, two hours of treatment per week are recommended.
6. Non-directive, non-verbal courses of therapy which do not lead to speaking either in the therapeutic setting or non-familial context within one year are to be rejected because they encourage maintenance and chronification of the mute pathology and support the subjective gain from illness.
7. Effective therapy approaches evoke a verbal communicative opening and first verbal utterances in spoken language within twenty therapy units.
8. Within an educational context, exemption from oral grades should be avoided as well as assistance in class. Both support the maintenance and chronic manifestation of silence and they can lead to a secondary pathology (cognitive and liguistic insufficiencies of the performance, secondary behavioural disorders).
9. Considering the fact that mitism is often accompanied by additional mental illnesses from a young age, a (non-verbal) evaluation for social phobia, depression and obsessive-compulsive disorders should be carried out and comorbidities should be taken into consideration in the treatment during adolescence and adulthood.
10. In particularly therapy-resistent cases, the indication for a flanking medico-therapy should be discussed. In terms of mutism, specialist literature recommends the active substance group of the so-called Selective Serotonin Reuptake Inhibitors (SSRIs). A medicinal support is to be embedded in an overall treatment plan.