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Evidence-based Practices for medications for children with SM and Co-morbid Disorders

September 15, 2009 Expert Chat Session


ananario 21:00:16 what will be the right dosage for an 8 yr. old child with sm?
ananario 21:02:12 what are the possible side effects of medication that I need to watch out and what are the most common medication for a child with social anxiety & sm?
emvcostello 21:03:29 Our 4th grade son has been on SSRIs since July, slowly building up to his current dosage of 5 mg per day. We have noticed no appreciable difference. The plan is to take another check point in mid-October and potentially up the dosage to 10 mg/day. Is this a normal protocol and usually how long does it take to see differences in a child who is "older" in terms of their SM diagnosis?
smgexpert 21:04:00 Welcome to our Expert Chat “Applying the evidence base to medications for SM” Our expert for this evening is Sucheta Connolly, M. D. Dr. Connolly is a psychiatrist who currently works for UIC Medical Center in Chicago. Along with his experience with kids who have SM, Dr. Connolly also has expertise in working with kids who have anxiety disorder and comorbid disorders. The rules for the chat room are posted on our website. To save time, I will not post all of them here tonight… just a couple of reminders: Be respectful, let the expert type in an answer to a question before asking another. Please do not advertise your business here without prior permission. Thank you, Dr. Connolly, for being our “expert” this evening. I am sure some of the attendees would like to know more about medications for children with SM .
edwardplimpton 21:04:15 And when do you make a decision to medicate
smgexpert 21:06:57 Also, please be aware I cannot give specific clinical recommendations on a given child without knowing details regarding the child that that only be obtained via a clinical exam. I can give general guidelines based on the evidence in childhood anxiety disorder, limited studies with medication in SM, and my own clinical experience. field of child psychiatry
smgexpert 21:09:00 I cannot give more than general guidelines based on the evidence from the literature in anxiety disorders, limited research in SM and medications, and my own clinical experience. Please understand I cannot give specific recommendations for a given child as I cannot do a clinical evaluation that would allow this to be done thoroughly. Dr. Connolly
Molly 21:09:39 I have 2 children who both have a predisposed anxiety disorder. They are both very severe, my oldest, my son (9), has ADHD, GAD, OCD, and PICA and my daughter (7) has been diagnosed with social anxiety, seperation axiety, GAD, enuresis, and selective mutism. They are both on several different meds to target each items specfically----has there been or do you know of a good mix of meds that help these types of things? Or would you keep trying to treat each item seperately?
Molly 21:11:01 They are all so hard to treat and I find that I keep running into brick walls, I just feel like there is someone out there that has done more research on childhood anxiety disorders and that we are missing something.
ananario 21:14:03 My son who is in 3rd grade was told by the teacher not to raise his hand if the voice will not come out, do you think this is right? I asked my son how he feels about it and he said he was hurt.
Molly 21:15:16 Wow, and this teacher is familiar with the whole selective mutism?
smgexpert 21:15:51 The dosing for an 8 year old will depend on severity of the SM/accompanying anxiety and the child's weight. For young children in general low doses are recommended of the SSRI medications. Prozac/Fluoxetine has been studied against placebo controls n SM in a small sample and in larger samples in childhood anxiety in general. Zoloft/Sertraline has also shown positive results in childhood anxiety in a recent large study. fluvoxamine/Luvox is the other SSRI studied in a large sample of children with good results. All have shown minimal side effects. In young children using liquid rather than pills allows clinician to start at doses such as 1 or 2mg/day on Fluoxetine for example, where the pills start at 10mg (could be cut in half for 5mg).
mprohl 21:16:30 How long have SSRIs been used with the population of patients with SM, and are there any longitudinal studies of long term effectiveness?
ananario 21:18:21 what is SSRIs?
stangye 21:19:35 SSRIs are Selective Serotonin Reuptake Inhibitors, a class of antidepressants. Prozac and Zoloft are two examples.
smgexpert 21:21:25 At low doses there is better opportunity to reduce risk for side effects. Common side effects to watch for on SSRIs include stomach upset, change in appetite (could be increase as well), headaches, activation/restlessness, difficulty falling asleep. Less commonly disinhibition where child starts disobeying rules, showing oppositionality, doing things without respect for consequences (things uncommon for the anxious child at baseline). Also if there is family history or diagnosis of bipolar disorder clinicians are cautious to prescribe SSRIs due to increased risk of hypomania and cycling into mania. Need to monitor closely for emergence of suicidal ideation, but this is less likely wiht anxiety disorders than depression. Many side effects improve after period and then resolve. If side effects on one SSRI medicaiton, another one should be tried.
mprohl 21:22:40 Do you recommend a trial of behavior therapy BEFORE medication, and if so, how long?
stangye 21:23:24 My 6 year old daughter started on 8mg Prozac/daily in July, with wonderful results. The plan is to keep her on it throughout this school year and wean off next summer. My question is that if it works so well, why do we need to wean off? My fear is that she will revert back to all the anxiety and SM.
ananario 21:25:30 how long does your child take prozac before you see result?
smgexpert 21:27:10 It is reasonable to proceed with increasing SSRI medication at pace that allows the medicaiton to build up adequate blood level. If no change or side effects then can be increased at 4 weeks. If still having improvement at given dose then good to wait full 2 months. The medications are used to decrease anxiety in these children, so the child can then participate in the therapy that helps them learn coping skills, strategies, take steps to feel more comfortable trying to communicate nonverbally or verbally, based on where they start at their baseline. some chldren show an improvement in first week of medication regarding decerase in anxious thoughts, more facial expressions, etc. but others take full 1-2 months to show effect. However, need to get to right dose in order to show effect as well. Again if little effect after maximum dosing trial, then try another SSRI. I often have to try several to find most effective one in a given child, though I routinely start with fluoxetine, and then sertraline.
Molly 21:27:27 Dr. Connolly, I read these statments like weaning off of medication and not giving a child an SSRI because of cycling mania and I find it very hard to understand. The selective mutism is a side effect to them of the anxiety disorders and I know that my children are not candidates to wean off medications. I am also concerned because my daughter has been on an anti psychotic and SSRI for many years now and we do have cycling mania as her depression runs very high around certain seasons. Does this mean she should not be on an SSRI?
smgexpert 21:29:15 Decision to medicate is based on several factors: severity of anxiety/SM, if depression is present along with the anxiety disorder (SSRI's are also effective for depression. Fluoxetine has most evidence. Then recently Celexa and Lexapro recently FDA approved for depression).
mprohl 21:32:36 I assume from your above response that you start medication concurrently with behavioral therapy? Also, could you respond re: longitudinal studies?
smgexpert 21:32:41 Decision to medicate is based on several factors: 1)Trial of psychotherapy/CBT has not been successful alone 2) anxiety/SM are so severe that child cannot even try therapy/CBT as too overwhelming (part of treatment is exposure to situations that increase child's anxiety so child needs to be able to tolerate this). 3) co-occuring disorders such as depression warrant trial of SSRI (Prozac has most evidence, also Lexapro and Celexa recnetly approved for youth with depression). Family history of success with medicaitons
ananario 21:33:21 my son only have anxiety in school since he was kinder and now 3rd grade now he is developing a tic only in school. therapist recommend to try medication. based on this should I really follow her recommendation?
quinnw 21:34:31 My son has been on a dosage of fluoxetine (prozac) for two years to lessen anxiety and associated Selective mutism, and we recently increased dosage to have more impact. We are seeing incremental/slow results. Are there other meds. which some children take in combination with prozac which have proven to have more impact on reducing inhibition about speaking?
smgexpert 21:35:56 For children with several co-occuring diagnoses med treatment depends on diagnosis. For anxiety disorders as a group and OCD SSRI's are first choice. For anxiety disorders in youth no other meds have shown consistent results in placebo-controlled studies yet. OCD literature is even more robust for SSRIs, and also for clomipramine (medication that is SSRI and tricyclic antidepressant, however this has more potential for cardiac and other side effects)
smgexpert 21:36:51 For ADHD stimulants, Strattera are approved by FDA for children. For depression and anxiety SSRIs are first line.
Molly 21:37:46 We started Strattera this summer, after trying several other things, does strattera help with anxiety as well? At what dose would this take effect?
smgexpert 21:38:05 For ADHD stimulants are first line and then Strattera are studied and FDA approved. For depression and anxiety SSRIs are best choice ( First Prozac/Fluoxetine has best evidence and then Celexa and Lexapro are FDA approved).
ananario 21:40:12 which is more effective the liquid or pills for an 8 yr. old child with sm?
smgexpert 21:40:24 Remember, medicaitons are one tool in the treatment of anxiety disorders/SM in children and need to be combined with therapy that helps children learn coping skills and other skills to help them reach their goals of improvement recovery. It is often a process that takes time.
quinnw 21:41:14 Has there been any studies of longer-term usage (more than 2-3 years) of side effects from Prozac in children? If it helps my son function more normally, would it be typical for a child to stay on it for a longer time (10 years). Also, how difficult is the weaning process, assuming a pretty high dosage?
smgexpert 21:42:25 SSRIs have been used in patients with SM for many years, but there are not long-term studies of medicaiton long-term effectiveness. Much more data is available for anxiety disorders and SSRIs, but even there studies have followed patients currently only 1-2 years out after placebo controlled trials. More research is needed regarding long-term effectiveness.
mprohl 21:42:47 We live in a rural area of NH and the average pediatrician has NO IDEA about SM, much less to whom to refer, medications etc. Is there some online source for pediatricians to learn more about this disorder and how to treat it?
quinnw 21:43:34 ok, I am wondering if there is any problem or risk of having a child on prozac for 10 years, as long as there is evidence that it helps him function well.
smgexpert 21:46:04 Behavior therapy/CBT is recommended first for SM/anxiety but if child does not show some response to treatment after several months (6 months) (not necessarily remission or full recovery, but improvement that shows potential for help with CBT), then should consider SSRI. I often see childern after therapy alone is not effective for several years, which is too long to wait without adequate results. Also remember, some children have anxiety that is so severe that behavioral interventions may be too stressful and despite their motivation they cannot partipate, then consider mediations to see if can reduce anxiety so they can participate.
stangye 21:48:28 We are doing play therapy with the prozac, but I am not very happy with it. After a few sessions, Katie has spoken to the therapist, but that is because she has the medication and is getting more comfortable. However, she is developing no skills to talk to an adult in the "real world". The play therapist said she is too young to comprehend CBT. She is 6. Do you agree?
smgexpert 21:50:56 Recomendations for weaning off SSRIs for anxiety/depression in children are the following, no specific ones currently for SM, but I follow same rules: Wean off slowly after full year of good results/recovery (not since med was started but since good results/recovery started). Start by decreasing in small increments. For child at 8mg this may be in 2mg increments. This way child can be maintained at lowest dose necessary for continued good functioning to keep side effects low. Incremently reduced in 2 month intervals to see full effects of lowering dose. If any symptoms return, then increase back up and wait another 6 months or so to try again. Reducing dose should be started at low stress period. Not just before school starts or other times when stress/anxiety increases. Some children and parents prefer to wait longer before reduction in meds are tried. giving child more time to get full benefit of therapy/meds to work on range of recovery issues and treatment goals. You do not have to wean off meds if not ready.
mprohl 21:52:02 Does letting this disorder go untreated (CBT or medication) make it less responsive to treatment, or more "entrenched" in the child's self concept/ defense mechanism vs. anxiety?
smgexpert 21:53:31 If your child has bipolar disorder that is stable on the antipsychotic it is OK to introduce SSRI cautiously for severe anxiety/SM along with the therapy. However need to watch cautiously for any increase in mania related to this. Many children with bipolar need SSRIs to treat their depression and are often on several medications to manage their syptoms at one time.
quinnw 21:54:22 what is the typical range you see of MG of Prozac for children with Anxiety/severe SMG symptoms who are 8-10 years old?
smgexpert 21:54:38 SSRIs are currently best choice for SM and anxiety.
quinnw 21:55:42 understood. how may milligrams of ssri (prozac) do children usually take dailY?
smgexpert 21:57:45 Need to consider if tic is related to anxiety or occurs in many settings. Tics can be worsened by stressors, anxiety, lack of sleep and some other factors. It is important to see that child receives therapy that includes CBT to help understand anxiety and develop coping skills. Medication can supplement therapy for the anxiety. Would not medicate just based on tics in school setting. Need to evaluate further to determine if tics are related to anxiety or if a separate tic disorder.
smgexpert 21:59:32 There is no evidence that shows Strattera helps with anxiety in research literature. However for children with ADHD and anxiety it is alternative to stimulants if stimulants lead to increased anxiety. However, stimulants are still first line meds for adhd/anxiety and should be tried first, in most patients they do not increase anxiety.
ananario 21:59:38 his tic is related to anxiety
ananario 21:59:50 what is CBT?
smgexpert 22:00:53 I am going to try to answer several more questions due to I started a little late this evening. Dr. Connolly
smgexpert 22:02:08 Liquid or pills are fine, depending on which is more comfortable for child. Pills start at higher dosing, so if lower dosing needed, then liquid is used, or if child cannot swallow pills
smgexpert 22:05:26 No longer studies in the literature currently, but clinically has been used safely over many years depending on severity of child's anxiety/SM. I have had many pts on for many years due to weaning leads to return of symptoms. Weaning process is same for higher doses and lower doses as I outlined earlier, small reductions every 2 months to see if symptoms return. This way can get to maintenance dose that is as low as possible. It will take longer to wean off higher doses as still wean off in small increments.
smgexpert 22:09:43 On good information sight for pediatricians is aacap.org which is american academy of child and adolescent psychiatry. AACAP Practice Parameter for childhood anxiety disorders reviews many of the things I have outlined here. I was one of lead authors on the this practice parameter. It covers anxiety disorders in general and includes SM. It also references medication studies. CAMS study recnetly compared placebo to SSRI sertraline/zoloft to CBT to CBT plus SSRI in children with anxiety (not specifically SM)and found combination was significantly better than either treatment alone and that either was much better than placebo (sugar-pill).
smgexpert 22:14:23 young children can participate in CBT that is modified to suit their developmental stage. It is good to find a therapist trained in CBT that works with young children. Play is often incorporated into any therapy with very young children as you want to make the therapy and engaging and fun for them. Also a positive reinforcement plant with frequent rewards with stickers, etc is very helpful so they are rewarded often for their efforst to try things that may increase their anxiety. Using puppets, heroes, toy characters, drawing, drama, roleplay are all a part of CBT with young children. They can learn relaxation strategies and are able to label their thoughts and feelings so they can learn self talk. These things need to be scripted for young children first and practiced so they can be successful. I could go on...but i need to focus on meds here.
smgexpert 22:17:34 Yes, letting it go untreated on does often lead to it becoming more severe over time. There are some long-term studies showing that this is the case. There is a subset of children who outgrow SM, when it is milder, but this is not most children. It is helpful to add meds and see if it can help child move forward when therapy alone is not enough. Some children feel their persistent anxiety is lifted for the first time when meds are successful and this at least helps them experience how their anxiety has been impacting them prior to that time.
ananario 22:18:26 I can not find a therapist that is familiar with sm, will a therapist familiar with only social anxiety be okey for a child with sm?
smgexpert 22:21:12 for 8-10 years olds with SM/anxiety I am often able to go to start Prozac at 2mg and go up 10mg with some good results. More severe pts require higher dose of 20mg (starting dose in adults). I do not start most teenagers higher than 10mg, and typically they need 20mg. For pts with severe anxiety/OCD/SM and comorbid depression,etc I have had to go as high as 40-60mg in older children and adolescents. I do this cautiously and monitor side effects closely. I am in a tertiary care center and do I see some of the most severe cases who are refractory to treatments elsewhere.
smgexpert 22:22:33 If tic is related to anxiety then it will improve with treatment of anxiety. I have seen this in several patients who have anxiety/SM
smgexpert 22:25:24 CBT is cognitive behavioral therapy. A great book for parents that reviews CBT in childhood anxiety disorders is "Helping Your Anxious Child", a new edition recently came out by Ronald Rapee and colleagues. It has accompanying workbook you can print out on-line. It is excellent and a paperback available readily! Also "Helping Your Child With Selective Mutism" by McHOlm and colleagues is another good resource that reviews CBT in SM.
smgexpert 22:26:22 Thank you for your interest in this topic tonight. I hope I was helpful in answering your questions. I am signing off. Dr. Connolly
ananario 22:26:54 Thanks Dr. Connolly.