All material Copyright © 2009 Selective Mutism Group ~ Childhood Anxiety Network
Reprinted with the express permission of SMG as originally published on their website.
PLEASE NOTE: This document was written for parents rather than clinicians. We include it here on this website so that therapists may learn from it and also share this information with the parents of their students and clients.
How is medication used in the treatment of SM?
The use of medication is based on the understanding that SM is related to social anxiety and there are medications that have been shown to help social anxiety disorder (or social phobia) in adults. In recent years, it has become clear that anxiety problems are related to an imbalance in some of the chemical messengers, or, neurotransmitters, of the brain. In particular, the neurotransmitter called serotonin seems to be involved.
Antidepressant medication in the form of serotonin reuptake inhibitors (SSRI’s) such as Prozac, Paxil, Celexa, Luvox and Zoloft are often prescribed in the treatment of anxiety disorders. In addition to the SSRI’s there are other medications that affect several of the neurotransmitters instead of just serotonin. Examples are Effexor, Serzone, Buspar and Remeron. Although none of these medications are approved by the food and drug administration (FDA) for use in treating SM in children, it is common for doctors to prescribe medications when there is reason to believe that they are safe and effective for a particular use.
There are several small-scale studies that have shown these types of medications to be effective in the treatment of SM. Of the few experts who have treated large numbers of children with SM, most report that these medications are very helpful and have a large margin of safety. Side effects are minimal and can usually be avoided by starting the medication at a very low dosage level and increasing it very gradually. Many children with SM seem to respond to a very low dosage of these medications so there is no need to keep increasing to higher levels. When combined with appropriate behavioral or cognitive-behavioral therapy, the treatment success rates are dramatically higher.
When medication is used as part of a treatment plan, the goal is usually to have the child take the medication for 9-12 months. This seems to be a sufficient time period to allow the child to decrease anxiety, become accustomed to speaking in most settings and for treatment gains to be maintained after the medication is stopped. When it is time to discontinue medication, it should always be tapered off slowly under a doctor’s supervision to avoid adverse side effects that can occur if medication is decreased too quickly.
When should I use medication in my child’s treatment?
The decision about whether or not to use medication should be made by consulting with a doctor who has experience using the recommended medications with children. The choice is also dependent on parents’ comfort level. Parents are encouraged to become as educated as possible about the types of medications used for SM and other treatment options by asking many questions of their providers and reading the available literature in order to make an informed decision.
Medication is not always necessary in the treatment of SM but in many cases it appears to be very useful in helping the child to take the first steps in overcoming their anxiety. Until anxiety is lowered to a tolerable level, most children will have difficulty accomplishing even small goals toward speaking. This is especially true in cases in which the child has exhibited the SM symptoms for a long period of time, other available treatments have not helped the child to make improvement, or in cases where the child is also showing symptoms of depression. Medication is more likely to be prescribed in such cases where the mutism is more severe or chronic (such as with older children and adolescents).
What are the signs and symptoms of SM?
Those with SM experience anxiety related to speaking and sometimes they may also be unable to make eye contact, nod their heads, point or make other nonverbal forms of communication when in a social situation that provokes anxiety. SM may be an extreme form of social phobia. Social anxiety and avoidance characteristic of social phobia may be associated with SM, and thus, both diagnoses may be given. More than 90% of children with SM also meet the diagnostic criteria for social anxiety disorder, now termed social phobia (Black et al., 1996). Diagnosis of other comorbid anxiety disorders is also commonly diagnosed with SM and social phobia (Biedel & Turner, 1998). The name change from ‘elective’ to ‘selective mutism’ in DSM-IV deemphasized the oppositional behavior connotation that a child elected not to speak and rather emphasized the characteristic of the disorder, that there are select environments in which speaking does not occur (APA, 1994). Thus a child’s reluctance to speak and engage socially should not be interpreted as an oppositional behavior but as avoidance due to anxiety. The term ‘selective mutism is consistent with new etiological theories that focus on anxiety issues (Dow et al., 1995).
The current edition of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, or DSM-IV-TR (APA, 2000), states that the following criteria must be met in order to qualify for a diagnosis of selective mutism:
(a) An inability to speak in at least one specific social situation where speaking is expected (e.g., at school) despite speaking in other situations (e.g., at home);
(b) The disturbance has interfered with educational or occupational achievement or with social communication;
© The duration of the selective mutism is at least one month and is not limited to the first month of school;
(d) The inability to speak is not due to a lack of knowledge of or discomfort with the primary language required in the social situation; and,
(e) The disturbance cannot better be accounted for by a communication disorder (e.g. stuttering) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder.
A diagnosis of SM can only be made by a treating professional qualified to diagnose mental illness. While many parents and professionals unfamiliar with SM may identify many of the symptoms in their children, a formal diagnosis should be obtained to confirm that SM is present and not better accounted for by other disorders that also include the lack of speech as a presenting symptom.
What behavioral characteristics does a child with SM portray in social settings?
Observation and clinical accounts of the behavior of children with SM are varied. It is important to realize that the majority of children and adolescents are as normal and appropriate as their peers when in a comfortable environment. Parents will often comment about how boisterous, sociable, humorous, inquisitive, talkative and even bossy and assertive these children are at home. However, what differentiates children with SM is their severe behavioral inhibition and inability to speak in certain social settings. When in these settings, children with SM feel as if though they are continuously “on stage” and experience many of the same symptoms that people have with stage fright. Some children with SM also report somatic complaints such as nausea, headaches, and stomachaches or may experience vomiting, diarrhea and an array of other physical symptoms before school or outings.
When in school or in other anxiety provoking settings, some children become much more withdrawn that others and may stand motionless and expressionless and may demonstrate awkward or stiff posture and body language. They may experience a great deal of emotions including anxiety, sadness and frustration but may not express these emotions visibly and some children have even been too inhibited to express feeling pain when injured on the playground. Many children with SM will turn away or hang their head to avoid eye contact, chew or twirl their hair or withdraw into a corner. Over time, some children learn to cope and participate in certain social settings by performing nonverbally or by talking quietly to a select few. There are also variations in the degree of outward anxiety or nervousness. Some children display facial expressions and body language that are obviously due to fear or nervousness. Others may appear outwardly calm and may be able to communicate nonverbally. It is the latter type of child that is most often misinterpreted as being defiant or oppositional since they do not show visible signs of being nervous.
Children with SM tend to have difficulty initiating and may be slow to respond even when it comes to nonverbal communication (e.g., pointing, nodding, shaking head no). This can be quite frustrating to the child and may lead to falsely low test scores and misinterpretation of the child’s cognitive abilities. It is for these reasons that assessment should be conducted by someone familiar with anxiety and how it may manifest in performance situations such as taking a test.
Social relationships can be very difficult for children with SM although some are well liked by peers. In many cases, classmates tend to take on a protective role and/or try to speak for the child with SM. Even for those fortunate enough to have supportive peers, there is no doubt that SM stifles social growth and development and limits social interaction. In worse case scenarios, some children are socially isolated, are victims of teasing and bullying and are completely unable to defend themselves. This seems to be more of a problem for older children and bullying may be more common for boys with SM than for girls.
Featured Organization: Selective Mutism Group ~ Childhood Anxiety Network (SMG)
We thank Selective Mutism Group ~ Childhood Anxiety Network for allowing PediaStaff to reprint their article. Selective Mutism Group ~ Childhood Anxiety Network is the nation’s premier resource for information on SM. SMG, a part of the Childhood Anxiety Network is a nonprofit organization dedicated to providing information, resources and support to those impacted by a child with the anxiety disorder known as Selective Mutism (SM). Visit their website at :www.selectivemutism.org