Wednesday, March 13, 2013

another way of treating Selective Mutism. Beware it's contraversial!

Now in the past I discussed the decision I have made in regards to medication in "to medicate or not to medicate" and I have been thinking recently on how I haven't thoroughly discussed the role of medication in treating Selective Mutism and at what point is it best to actually start down this mode of treatment. As my blog describes Selective Mutism is a journey and we all hope it is a journey that has an end, successes and some failures but we all hope that our children will recover, so what we do when it's not working? I think a parent needs to consider the following:

- Is the intervention program in place
Firmly I believe for one to embark on the medication route it is SOO important to make sure that your child has the appropriate support in place. This includes a few things a school program (sliding in), the support of a psychologist and a paedatrician, parent intervention and exposure,  an awareness of the complexities of Selective Mutism with all those working with your child. 

- An assessment of where your child is at
To know how far you have come, I think it is vital to know where they have come from using a tool such as the anxiety inventory scale that I have discussed before will be beneficial to assess how they are going. Also it helps us to identify where the focus of intervention should be placed and where the child is at in the stages of communication.

Most importantly I think we need to look at the symptoms of Selective Mutism that are present.  I found this link from the SMART Centre really helpful and thorough, it even enlightened me a little please check this out and mark/highlight the symptoms that are seen in your child "What is Selective Mutism". If we identify the symptoms then we can see when they disappear and watch the transformation of the child. 

- Is your child willing
This is not the be all and end all, but I think knowing where your child is at will help you in your decision. How do they talk about SM are they wanting to speak or are they reluctant. This can help you make your decision about cognitively if they are able to understand what is happening inside of themselves, their mind and how they can overcome their condition.

Once you have considered these factors I think the next thing that is helpful for any parent is to look at the research and experience of others in treating Selective Mutism with medication.

While researching for this blog I come across this question and answer newsletter from the Selective Mutism Foundation he discusses medication and how it works with Selective Mutism, you can read the full newsletter here (I have included it below this post). It is wise to take your research further, what I found interesting was the majority of studies in Selective Mutism and medication they refer to fluoxetine also known as Lovan. Some studies that have been carried out on the effectiveness of fluoxetine and Selective Mutism are:

Selective Mutism: A Review of Etiology, Comorbidities, and Treatment this article discussed Selective Mutism and the different models of treatment. The Author discusses the studies that have been undertaken in how medication can be used to treat Selective Mutism.

Amongst other information this author discusses that when behavioural interventions have not been successful"Given these cautions, fluoxetine, or Prozac, is an antidepressant medication that has been shown to be quite beneficial in treating Selective Mutism, particularly when combined with other learning or behaviorally based therapies. In most, if not all cases, the medication can be discontinued after the child begins normal speaking because the child’s speaking will be maintained by reinforcement in the natural environment."

We can keep going as I discovered when I researched it, there is a lot research into the effect of medication in it's treatment of Selective Mutism. Now I have to admit there is a lot of negative press about medicating children. Some will tell you it is outright wrong. This I will say the opinion of a honest parent who wants the best for their child takes priority over other opinions. I don't believe for a second that a parent would medicate their child unless it is needed (maybe some).

There comes a time when a parent of a child with Selective Mutism may need to consider medication and is it something that will help their child. This is not a simple decision. But one I believe needs to be made with deep thought considering the impact on their lives and the commitment to the progress that is needed. Medication without a intervention program in place before it is commenced is lazy and ill advised at best. The effectiveness of the medication is reduced if we as parents aren't taking the steps necessary to enable our children to overcome their fear. 


"You answered my question about Prozac in a previous newsletter. I’m ready to start looking into treatment for my twin 8 year old daughters. My question is: Who do I need to tell that they are on medication? Should I share this with their older sister, stepsister and stepbrother? I know of a teenager who was on Prozac when a friend found out, the whole school knew and teased her. Prozac has gotten such a bad “rap” I’m not sure who to share this with. 

Confidentiality is important. Nobody but parents and doctors needs to know anything about the psychiatric treatment of your children. Even in our relatively enlightened modern times, there is still stigma attached to treatment for mental disorders. We all wish it were not so, but this is a fact of life. It may be difficult to hide the fact of medication treatment from family members, so a parental discussion with siblings about the importance of confidentiality and privacy may be a good idea. Teachers and classmates do not need to know details of treatment or medications and it should be the parent’s decision who is told anything about a child’s treatment. It is a private matter between doctors and patients and should be treated as confidential medical information as required by law. 

For those of us who have chosen courses of medication to treat fairly severe cases of Selective Mutism, how long would you keep a preschooler on fluoxetine without significant improvement before you decide that a different medication should be tried?
The answer to these questions is not simple. In my practice, I have never encountered a preschool-aged child who did not respond to fluoxetine (Prozac). First, let’s define what is meant by “significant improvement” with treatment. Some clinicians and parents might view this as meaning completely well, with no signs of any emotional or behavioral problems. However, in research settings, it usually means that outcome measures showed statistically meaningful improvement with treatment, even when patients might still have “significant
improvement” with treatment. Some clinicians and parents might view this as meaning completely well, with no signs of any emotional or behavioral problems. However, in research settings, it usually means that outcome measures showed statistically meaningful improvement with treatment, even when patients might still have significant symptoms and not be considered well. I shall use it to mean something in between these two extremes: a child whom everyone involved agrees is functioning much better, even if some mild symptoms persist. 

There are several possible explanations why a young child on medication might show inadequate response. Perhaps the lack of response is due to a dose that is too low. Some children have side effects, which necessitate using lower doses, but most children tolerate Prozac 20 mg per day very well, and I try to get all kids up to this dose, regardless of age. However, doctors with less experience treating young children may be overly cautious, and never raise the dose to the effective range. This is perhaps the second most common reason for the lack of pharmacologic response in proven psychiatric treatments in general. The most common reason is that the patient does not actually take the medication as prescribed and does not tell the doctor that they are not taking it, leading the doctor to conclude that the drug is not effective for the patient. 

Another explanation is the time needed for medication response of social anxiety and mutism. Our first study of Prozac at Columbia University only measured treatment effects for 9 weeks. Many of the children were showing “reduced” social anxiety at the ninth week, but had not yet overcome the mutism in important settings like school. Dr. Black’s study at NIMH also found only partial improvement after 12 weeks. Our second study, designed to overcome this problem of time, examined effects of Prozac for 17 weeks. This study and clinical experience have shown that it may take 4 to 6 months at a reasonable dose to see a good response to Prozac, where a child is beginning to talk in school and has few symptoms of anxiety. 

If neither of these reasons is true of the case in question, I would consider raising the dose and adding a behavioral treatment plan. If an increased dose is not possible, due to side effects, I might consider trying a different medication if a child has no improvement after 6 months on Prozac. However, this has never happened on one of my preschool-aged patients, so I do not have any experience with other drugs for very young children. 

What drugs other than fluoxetine have been used successfully with young (pre-school) Selective Mutism kids?
As mentioned above, I do not have direct experience with other medications in very young kids. I do not know specifically of studies to examine the safety or efficacy of other medications in children under school age. Most research review boards have traditionally been reluctant to approve psychotropic medication studies in preschoolers, and our formal studies only went as young as age 5 after we showed the Institutional Review Board that Prozac appeared to be very safe in the 6-12 age group. In non-research settings I have used Prozac in children as young as four with good results. Other medications to consider include Luvox (fluvoxamine), which is similar to Prozac, phenelzine (reported in a single case report of a six-year-old with Selective Mutism). Anafranil (clomipramine), and some of the newer psychotropic medications for which use in anxious children has not yet been reported din the medical literature. Each of these has pros and cons as the next choice and none are formally FDA-approved for this use or age group (but neither is Prozac). Talk to your psychiatrist about these issues. 

Are there any studies available (or even in progress) that discuss the long-term effects of fluoxetine?
There are not specific studies in children, to my knowledge, which address this question systematically with a long-term follow-up design. Prozac has been the top-selling antidepressant worldwide for many years now, and has been used by many millions of people. Post-marketing surveillance by the manufacturer reports of adverse effects of Prozac (as required by the FDA) has not detected any serious long term problems from the medication, even in patients maintained on it for several years for illnesses such as Obsessive Compulsive Disorder and depression. There are studies, which indicate that it does not increase risk of birth defects in pregnant women, an importing fining supporting its safety in general. There is no evidence to date that it has any long-term harmful effects.

I have twin eight-year-old girls (fraternal) both with Selective Mutism. In kindergarten, they went for “play therapy”, I was told they would grow out of Selective Mutism, just keep “gently encouraging” them. Now they are in third grade and attending therapy. This doctor is trying relation therapy. They will both talk at home to parents, siblings, and relatives. They will talk at relatives houses. They will talk to friends at our house. When they visit friends, they will talk to them, but not the parents or other siblings. They will not talk at a friend’s birthday party. They will talk at family parties, or their own birthday party. They won’t talk at activities outside school such as Brownies, or gymnastics. They won’t talk to their friends in school, not even at recess. They will whisper to their teachers, when the teachers request a verbal response. I have heard other children have been “cured” with Prozac; can you explain the pros and the cons? At what age or point would you recommend oral medication? Can you recommend another form of therapy for us to try? 

This description of the symptoms of Selective Mutism in these girls is typical of children I have seen, although many children will not even whisper to teachers. This parent does not indicate whether whispering to teachers is a result of treatment or the girl’s baseline behavior. In the experience of patients who have come to play therapy, family therapy and me have not helped at all. More directive and behaviorally oriented approaches to overcoming anxiety have helped some children according to an uncontrolled case report literature (“uncontrolled” means the treatment lacked an experimental design necessary to prove scientifically that the treatment works and is more than a placebo effect). Such treatment should involve a stepwise “desensitization” plan for speaking in different settings, with rewards for each goal on the ladder, perhaps including, but not limited to, the relaxation techniques mentioned above. The idea is to start with the least anxiety-provoking new speech goal, such as speaking to a friendly neighbor, and as the child succeeds at the easier goals, gradually move toward the more anxiety-provoking goals, such as speech in the classroom. In my experience, if such behavioral treatment does not result in significant improvement in six months to a year (see the beginning of this column for my definition of improvement), it is time to try medication, since the child has not responded to non-medication treatment. 

Prozac works to reduce the excessive anxiety and inhibition, which underlies the mutism. Over time, it resets the hair-trigger for anxiety responses described above. Children under about 10 years old usually get an excellent result in four to six months. Older children, who have been struggling with the disorder much longer, and are much farther behind in terms of social skills development, seem to get the reduced anxiety and inhibition from medication, but often fail to change speech behavior in school with the same ease as younger kids. They may need additional work on behavior skills to overcome the fear of speaking and try new social behaviors, especially in school. They are struggling with more than just the anxiety; they must fundamentally change their self-concept and develop new social behaviors that other children mastered much earlier in life. It is no longer a pure anxiety problem, but has also become a character development problem. This is why I tell parents not to wait too long to try medication if other treatments have not succeeded. In the case of the twins presented above, non-medication treatments seem to have failed for several years. It is time to add medication

The cons of Prozac are the possibility of side effects, which are typically mild, transient, and easily managed with dose reduction. Most children do not have any problematic side effects if the medication is started with a low dose and gradually increased. In children with Selective Mutism, the commonest problems include excessive disinhibition (an overshoot of the therapeutic response, easily managed by lowering the dose), insomnia, stomachaches or diarrhea. Also reported in adults, but uncommon in children, are headaches, appetite suppression and increased nervousness. Rarely, as with any medication, a rash may occur which required discontinuation of the drug. "

1 comment:

  1. weight gain and sedation. Further long-term studies are needed to determine any long-term side effects.