Medication as a tool in the treatment of Selective Mutism

Lmkoll [2012/01/23 20:53:23]: Hi everyone! Glad you are here! Our moderator and expert, Dr. Yu, should enter the room shortly.

verajoffephd [2012/01/23 20:55:17]: Expert Chat: January 23, 2012. 9 pm Eastern Time. Welcome to our Expert Chat this evening. This is Dr. Vera Joffe, from the Board of Directors of SMG, neurodevelopmental psychologist with specialty in Selective Mutism, Coordinator of the Expert Chats. I will be monitoring the Expert Chat with the goal of allowing us to enjoy and learn from our Expert in the most efficient, ethical, helpful, and helpful way. I am much honored to have Dr. Genevieve Yu. Before I introduce Dr. Genevieve Yu, I would like to remind all participants that 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. In addition, we want you to know that although Dr. Genevieve Yu may answer questions from parents, teachers, professionals, and others, she will not make specific recommendations for a child given the fact that he does not have a professional/therapeutic relationship with the people attending this meeting. Thus, when asking questions, remember that Dr. Genevieve Yu will be able to answer your questions in a more general manner, and she may direct you to discussing strategies and tools with other professionals, when indicated. Now, to the technical details of having an “Expert Chat” that is actually a “Written Chat”: One of the tools we have used in previous chats was to have some “signs” to help people start a question, and to tell others when they are done asking the question. Here are the signs that we can use to help people ask one question at a time, and to give the Expert time (and space) to answer the question: ( to start) to finishAt times, the monitor may have to say something, and this is the sign for that clue: !I wish you all a very informative and helpful Chat. Now, we are ready to start: Dr. Genevieve Yu M.D. is a private pediatric and adult psychiatrist who is Board Certified by the American Board of Psychiatry and Neurology. She trained at UC San Francisco (UCSF) for child and adolescent psychiatry, UC Los Angeles (UCLA) for adult psychiatry, and graduated from UCSF Medical School and MIT University. Dr. Yu focuses on providing personalized and specialty care to children, adolescents, adults, couples and families. One of her specialties is the evaluation and treatment of Selective Mutism, as well as Social Anxiety, OCD and other anxiety disorders in children. Dr. Yu has a private practice office in Orange County, California, and offers care through Telepsychiatry as well. We can now start the questions.

frobles [2012/01/23 20:55:58]: I have a 6 year old girl with SM; her height is 3’9 inches and weighs 52 pounds. She is on 2.4 ml of Prozac daily. Would you be able to tell me what a normal dosage is based on her age, or how much further we can go on the med without putting her at risk? She has showed significant progress in these 7 months where that she’s been undergoing treatment but there is still some improvement needed when it comes to defending herself at school when teased by classmates.

genevieveyu [2012/01/23 20:57:30]: Hello everybody! This is Dr.Genevieve Yu. Thank you for welcoming me to the Selective Mutism Group Chat.

genevieveyu [2012/01/23 20:58:29]: @frobles: Thank you for your question. I can answer questions with general guidelines although I cannot give specific clinical recommendations because we are not in my office.

genevieveyu [2012/01/23 20:59:14]: @frobles: For SM, years of research and experience have shown us that Prozac is the first drug typically tried when medications are warranted.

genevieveyu [2012/01/23 21:00:54]: Although Prozac is FDA-approved for children, the lowest age it is approved for is 8 years old. For this reason, we extrapolate for dosing for younger children. As low as 2mg can be started and then slowly increased over time to achieve therapeutic levels.
verajoffephd [2012/01/23 21:02:14]: Dr. Yu: Can you please comment on how the parents and the school staff can collaborate to help the child with the teasing that is going on?

elizabethanneallen [2012/01/23 21:02:16]: I am wondering if in general the benefits outweigh any possible negative effects of placing a child on meds? Also, does the medication help to change the brain chemistry so the child does not have to stay on meds forever?

genevieveyu [2012/01/23 21:02:56]: I'm glad to hear she is showing improvement.

Shellijenkins [2012/01/23 21:02:57]: I have heard that Zoloft is also used sometimes. How does that compare with Prozac? We have never tried medication on our daughter yet (age 6). But, we have been to months of non-medicated therapy without much success. Also, are there any known side effects that you have noticed in treating young children with medicine?

frobles [2012/01/23 21:03:18]: So for my daughter 2ml we have not reached a theraputic level?

genevieveyu [2012/01/23 21:03:44]: If that is the last step in her improvement then it sounds like increased collaboration and coping skills, including behavioral supports, to cope with the teasing and self-esteem would be helpful.

genevieveyu [2012/01/23 21:04:27]: @frobles: Typically we do not measure therapeutic levels of Prozac to determine a window. It sounds like the medication has been helpful so I would say that it is therapeutic.

frobles [2012/01/23 21:05:00]: Very good. We are just fearful about putting her at risk. thank you so much

jenniferlish [2012/01/23 21:05:00]: Hello. This is Dr. Jennifer Lish. I do cognitive behavior therapy for Selective Mutism. Are there any randomized controlled trials or less rigorous research studies of kids with Selective Mutism or Social Anxiety Disorder that could provide us guidance re: with whom and for how long to do solely CBT before considering the addition of a selective serotonin reuptake inhibitor, or whether combination treatment with CBT and an SSRI is superior to solo treatment with either an SSRI or CBT?

genevieveyu [2012/01/23 21:05:52]: @elizabethanneallen: Yes, the benefits of an SSRI such as Prozac often outweigh the potential side effects. SSRIs (selective serotonin reuptake inhibitors) increase the levels of serotonin in the brain, which is the neurotransmitter critical to alleviate anxiety.

genevieveyu [2012/01/23 21:07:09]: The most common side effects of SSRIs are often short-lasting in the first week or two, such as stomach upset, headache, flu-like symptoms. Usually SSRIs are very well tolerated. Of course there are many potential side effects.

elizabethanneallen [2012/01/23 21:07:28]: Okay , thank you Dr. Does that mean the child would not have to stay on the meds very long for it to be effective?

jenniferlish [2012/01/23 21:09:10]: Perhaps Dr. Joffe and Dr. Yu could both provide some general ideas about when it makes sense to try an SSRI. I have not treated many cases of SM. I have had great success in just a few sessions of CBT (graded exposure with positive reinforcement) without meds, but the child was four years old so I wonder if the rapid success of CBT without meds was due to her being so young. I wonder if treatment with cognitive behavior therapy would be more difficult and take longer and have a lower chance of success with an older child with a longer history of mutism.

genevieveyu [2012/01/23 21:09:34]: Oftentimes after starting an SSRI for a good trial (6 months to 12 months) with a good response and in combination with therapy, significant benefits are seen. The child may have learned skills to continue being successful in anxiety-provoking situations even after the SSRI dosage is lowered. Lowering the dosage is recommended in very slow increments and in low-stress times.

genevieveyu [2012/01/23 21:12:30]: @jenniferlish: Unfortunately we are very limited in the number of studies that are available. Generally, a dedicated trial of therapy with an experienced therapist who can engage in behavioral techniques (oftentimes combining with play modalities for young children) can be atleast 6 months. After that, I often get asked to evaluate if medications would be helpful in addition to continuing therapy.

Phillipssa [2012/01/23 21:12:57]: My son is 16 with SM. How often would you recommend him going to therapy as far as trying CBT. He still will not speak in school to teachers or peers.

genevieveyu [2012/01/23 21:13:43]: @jenniferlish: We can extrapolate the recent CAMS study which shows that for anxiety, therapy + SSRI treatment is superior to either therapy alone and SSRI alone, which is superior to placebo.

genevieveyu [2012/01/23 21:14:26]: @Phillipssa: I would absolutely recommend that your 16 year old son try therapy, such as CBT.

genevieveyu [2012/01/23 21:16:17]: He would likely benefit from establishing a relationship with a therapist who he feels a strong repoire with, as adolescents often do, in order to engage in successful treatment. Since his symptoms are long-standing and sound severe, I recommend that you consult with a psychiatrist at an early point in treatment to have the option of medications available. I am guessing (from what I know) that he might benefit from both modalities.

Shellijenkins [2012/01/23 21:18:00]: We are considering SSRI. We have heard that Zoloft is also a possibility. How does it compare to prozac in your experience?

genevieveyu [2012/01/23 21:18:10]: @jenniferlish: I have had patients of all ages who benefit from medications, as young as 4 years old and up. Most often, there are two situations: 1. the patient cannot utilize the therapy because of severely high anxiety levels, and the medication helps alleviate that so that he/she can engage in therapy. 2. the patient has shown mild improvement from therapy but continues to have symptoms that benefit from the addition of medication.

genevieveyu [2012/01/23 21:20:00]: @Shellijenkins: Yes, Zoloft is another SSRI which is very effective and helpful. Since Prozac is the oldest SSRI, we have the most data and consider it to be the safest. Since SM affects children of very young ages, safety is imperative. However, Zoloft is typically the next SSRI used if Prozac is not beneficial or if someone has side effects and cannot tolerate Prozac. The recent CAMS study showing that therapy + SSRI to be very beneficial used Zoloft.

genevieveyu [2012/01/23 21:21:24]: There are unique medication profiles for Prozac and Zoloft which also help to determine which one a patient might benefit from more. For example, Prozac often gives people more energy, and Zoloft helps people sleep. Prozac should be taken in the morning and Zoloft at night. If a particular patient benefits more from either of these considerations, that can be a reason to choose the medication.

verajoffephd [2012/01/23 21:21:31]: Dr. Yu: Regarding the question about an adolescent who is showing symptoms of Selective Mutism, I support your recommendations strongly as it is often our experience that if an adolescent has S.M., he/she is likely to have symptoms of other kinds of anxiety, and difficulties in areas of socializing, academic, and emotional as well. Thus, intervention should be done as a team of professionals, such as psychiatrist, mental health professional who works in the area of CBT (Cognitive Behavior Therapy), and also at school. An adolescent who is in Middle or High School may need to be considered for accommodations, or even special education.

Shellijenkins [2012/01/23 21:23:22]: Do you have any recommendations for professionals in the Greater Salt Lake City, Utah area. Our previous therapist has moved and we are not sure we really saw any improvement over a period of about 6 months. We would be interested if you had any colleagues in our area that you could recommend.

genevieveyu [2012/01/23 21:23:35]: @Phillipssa: Oftentimes CBT can be initiated at 1x/week for 1 hour a week, and may increase in intensity to benefit the patient's symptoms accordingly.

genevieveyu [2012/01/23 21:24:57]: @Shellijenkins: I personally do not know anyone in the SLC Utah area, but I'm sure that the SMG would be helpful to find a recommended professional.

akotrba [2012/01/23 21:26:09]: Dr. Yu: Related to the adolescent question - I have been seeing a 14 year old in therapy for approximately one year. His symptoms are quite severe. He has been making slow gains. He has been on Prozac 40mg since much before I began seeing him; it doesn't seem to be alleviating his sypmtoms (according to parents, school, and my observations). Would you consider changing to a different medication or continue simply working through CBT/school consultation?

verajoffephd [2012/01/23 21:26:34]: Dear Shellijenkins: Thank you for asking for a professional in Salt Lake City. We will look into our data to find out if there is anyone that our Professional Board is familiar with, but you can start looking for the Utah Psychological Association, and then find out who is experienced in CBT in that area.

Shellijenkins [2012/01/23 21:27:28]: Thank you verajoffephdIn your experience, when a child is weened away from the SSRI, after showing improvement, do they typically retain that improvement or do you see the child regressing and having to go back onto the medication?

Shellijenkins [2012/01/23 21:28:28]: Sorry, that should have been two separate posts. The second part is to Dr. Genevieve

loispw [2012/01/23 21:29:14]: Hello,this is Lois Plitt Warren. I am an art therapist working with children with SM. When a child has shown great improvement, and the Dr. and I agree that Prozac should be slowly reduced, how long does Prozac continue to remain active in the child's system? Are there any withdrawal symptoms? If it is found that the Prozac is still needed, are there any contraindications for going off and on Prozac? Thank you.

genevieveyu [2012/01/23 21:29:16]: @akotrba: Oftentimes levels of Prozac or any SSRI require higher levels. At low doses, SSRIs work as antidepressants and at higher doses they work as both antidepressants and anti-anxiety medications. As we understand SM to have a basis in anxiety, oftentimes the doses need to be high. Adolescents often can tolerate medication dose ranges that are fitting for adults, meaning Prozac 60mg.

jenniferlish [2012/01/23 21:29:34]: Thank you Dr. Yu. I am somewhat familiar with the CAMS study, but I should read the published paper again. Drs. Yu and Joffe, I will be attending a meeting at the school that one of my patients with Selective Mutism attends later this month. This child has been on an IEP for 18 months with no improvement whatsoever in her selective mutism. She is still mute in the public school classroom. I have used CBT to get her to talk to non-family adults and children in my office building, in the community, at a local children's museum, and at a coffee shop. Since the CBT treatment, she has talked to adults and children while in the company of her parents. I also visited her daycare and got her speaking and interacting there. I want to argue effectively in the meeting at the school to get them to do graded exposure with positive reinforcement in the public school classroom. I want a paraprofessional or a teacher to do that at school. Any suggestions what I can say to convince the school that it is their responsibility to do that work?

genevieveyu [2012/01/23 21:30:11]: And in general, I recommend maximizing and optimizing one medication before finishing a trial to switch or add another medication.

jenniferlish [2012/01/23 21:31:16]: Dr. Yu, in teenagers who are the size of adults, do you find that you need to use doses of SSRIs for SM that are comparable to the doses that are often used for OCD (e.g. 60 mg. Prozac, 300 mg. Zoloft)?

genevieveyu [2012/01/23 21:32:24]: In terms of decreasing medication doses to taper off, oftentimes this is done after the patient has shown benefits and we know the medication has reached a stable level. For Prozac, this can be at the minimum 2 months. I recommend trials of 6 months to 12 months.

genevieveyu [2012/01/23 21:33:41]: To taper down, this must be done slowly and with the supervision of a psychiatrist because there are potential side effects such as flu-like symptoms, headaches, nausea, stomach upset, and if tapered too quickly, can be much more severe.

genevieveyu [2012/01/23 21:34:36]: Prozac can stay in the body for several weeks, so after the last dose, you must wait 2-4 weeks to see if there are any changes.
verajoffephd [2012/01/23 21:34:52]: Dear Jennifer: Thank you for all your questions regarding school, I.E.P., and the discussion of who is responsible for providing the CBT (and the exposure element of therapy) at school. These are good questions and topic for one of our next Expert Chat as Dr. Yu is answering your questions about medication related issues. Thank you for bringing up such important issues for future discussion.

genevieveyu [2012/01/23 21:35:22]: Many times the child maintains their success because they have learned positive skills, and does not require continued medication.

genevieveyu [2012/01/23 21:36:42]: @jenniferlish: Yes, since we understand that the biological etiology of SM is anxiety, we oftentimes need higher doses of medications similar to what is needed for OCD, another anxiety-based disorder.

verajoffephd [2012/01/23 21:37:00]: Dr Yu: When is the best time to attempt a decrease of the medication? Would summer be a good idea? Should children who go to camp stay on medication as they will face a new situation? Should medication not be changed right before the academic school starts?

genevieveyu [2012/01/23 21:39:27]: @verajoffephd: The timing of when to attempt decreases of medications is very important. Ideally, times with the least stress, including changes and school-related activities (starting school in the fall or returning to school after long vacations), and new situations (oftentimes anxiety-provoking) are best for decreasing medications. If medications are decreased at a stressful time, then we will not know if the medication decrease or the stress potentially cause any increase of symptoms.

jenniferlish [2012/01/23 21:39:35]: Thanks so much for your answers, Dr. Joffe and Yu. This is very enlightening. Dr. Joffe -- might www.abct.org, www.childanxiety.net, www.ocfoundation.org, www.academyofct.org, www.pcit.org be good places to look for a cognitive behavior therapist who is competent to treat Selective Mutism? Or do you find that very few cognitive behavior therapists have sufficient expertise specifically in the treatment of selective mutism, so that these sites would not be useful?

Gsaldua [2012/01/23 21:39:36]: gsaldua: Dr. Yu, is having seizures one of the side effects of Prozac or Zoloft? Thank you very much.

genevieveyu [2012/01/23 21:40:42]: Medications are best decreased after the benefits are gained and sustained for several months.

loispw [2012/01/23 21:41:08]: If during a very slow tapering off period, a child exhibits the side effects you describe, what do you suggest to alleviate the discomfort?

genevieveyu [2012/01/23 21:42:40]: @Gsaldua: Yes, a serious potential side effect is seizure, but this is a very rare side effect. Of course close monitoring must be done after starting any medication, and also in particular if the patient has a pre-existing health condition such as seizures.

Shellijenkins [2012/01/23 21:43:53]: When trying SSRI (prozac) for a young child (age 5-6), is it good to let the child know they are taking medicine for the SM, or is it better to try and insulate the child from that, so they don't think they need the medicine to fix something that is broken or that they are broken and can only be fixed when taking medicine. Is that even an issue for children??

genevieveyu [2012/01/23 21:44:02]: The probability of having the side effect of seizure is remarkably low, and likely shouldn't be a contraindication to trying Prozac unless there is a known seizure disorder.

genevieveyu [2012/01/23 21:45:51]: @loispw: During a slow taper, if the child experiences side effects, the dose can be raised again temporarily to minimize those side effects if they are intolerable. Most likely those side effects would remit after a few days, but each individual child would need to be supervised closely by a psychiatrist.

genevieveyu [2012/01/23 21:47:39]: @Shellijenkins: Absolutely, I encourage education in a positive outlook and optimism with every child who starts medication. Of course, it is the parents' decision, but I have found that the most successful families are those that are open about taking medication. The child dose not need to know all the details, but the message of taking something to help them is important and not a crutch.

jenniferlish [2012/01/23 21:48:05]: Drs. Yu and Joffe: As you know, parents are sometimes reluctant to have a child take a selective serotonin reuptake inhibitor, even if the child is really suffering, his or her functioning and development is quite impaired, and a vigorous trial of state of the art CBT has been ineffective. Obviously, it is a parent's perogative to make that decision. But if a parent is on the fence, what would you tend to say regarding the costs and benefits of an SSRI for SM or another severe anxiety disorder for such a child?

verajoffephd [2012/01/23 21:48:17]: Dear Shellijenkins: You have a very good question about the child's knowledge about the medication, and the reason for taking it. I totally agree with Dr. Yu that it is very important for children with S.M. and with other kinds of anxiety to be an active element in the treatment. As a matter of fact, the more the child feels that he/she can make changes, the more likely he/she will respond well to treatment. Thus, it is best to be honest and upfront with the child and educate the child and parents about medication with the goal of taking any preconception and stigma about medication and bringing this as a positive tool in the treatment.

genevieveyu [2012/01/23 21:48:45]: I oftentimes compare taking medication in an age-appropriate way for the child, such as wearing glasses for a toddler, or having asthma for a school-aged child. They are familiar with these conditions and understand that their bodies cannot control having poor vision but they choose to help themselves by wearing glasses.

loispw [2012/01/23 21:48:59]: Thank you.Certainly I agree that any child taking SSRI's are closely supervised by a psychiatrist.

Shellijenkins [2012/01/23 21:49:42]: Thank you, both. That is good reasoning for being upfront.

genevieveyu [2012/01/23 21:49:54]: I highlight the importance of taking any blame from the child, and say repeatedly to them that it is not their fault.

genevieveyu [2012/01/23 21:53:19]: @jenniferlish: The costs of Prozac should be a consideration just as the cost of any treatment should be. Luckily, most insurance policies will cover the cost at a low price because it is off-patent (generic). I strongly believe and have seen dramatic changes after a child has started medication.

verajoffephd [2012/01/23 21:54:04]: We will be ending our very informative Expert Chat in a few minutes. I would like to ask any of the participants who have not yet asked a question to have an opportunity to ask a question to our wonderful Expert. We will certainly ask Dr. Yu to come back again in the near future as we learned so much from her in such a short time.

jenniferlish [2012/01/23 21:54:27]: This is Jennifer Lish, Ph.D. Is it known at percentage of children with Selective Mutism also meet diagnostic criteria for Major Depressive Disorder? Also I just want to express my gratitude to Drs. Yu and Joffe, for your time and generosity. This is a terrific public service.

genevieveyu [2012/01/23 21:54:54]: These benefits can be seen as soon as a few days after starting the medication, or can take up to a month or two. We are lucky that SSRIs in general are very effective with few side effects, and for this reason I think a trial is warranted after therapy has been tried.

Shellijenkins [2012/01/23 21:56:02]: Thank you for the information and for your time.

verajoffephd [2012/01/23 21:56:07]: We are almost in the end of our Expert Chat discussion. I would like to thank Dr. Yu for her time, expertise, and wonderful contribution to our group tonight. We would like to ask you to please send us an email with feedback about this talk, and also to let us know about possible topics you would like to be covered in our next Expert Chat. We will have one Expert Chat in the spring time, and we would love to hear from you of themes and topics of interest. Please, let us know as we want to serve the needs of our members, as we thank you for being part of this very important organization. Please, email the website or to Dr. Vera Joffe so that we can receive your feedback and plan the next Expert Chats. Sincerely, Vera Joffe, Ph.D. (from the Board of Directors), Chair for the Expert Chat.

loispw [2012/01/23 21:56:09]: Do you feel there is a maximum length of time that a child can safely be on an SSRI?

genevieveyu [2012/01/23 21:56:19]: @jenniferlish: I don't believe we have a study showing a percentage of comorbity of SM with MDD, but I would not be surprised if many kids with SM experience depressive symptoms. Both therapy and medication can help with depressive and low-self-esteem symptoms as well.

mswisher [2012/01/23 21:56:37]: Thank you for the great information tonight

genevieveyu [2012/01/23 21:57:52]: @loispw: There is no study showing that a particular time period that is too long - we know that there aren't any prohibitive or long-term side effects that would dictate stopping at any particular time.

genevieveyu [2012/01/23 21:58:24]: You're welcome and thank you everybody for your great questions, and to Dr. Joffe and everybody at SMG for inviting me as the expert this evening.

jenniferlish [2012/01/23 21:58:47]: Thank you so much.

verajoffephd [2012/01/23 21:59:00]: Thank you, participants, for your great questions. We will certainly review them again, and we may have a summary of Dr. Yu's suggestions and review of the current research and literature on medication for Selective Mutism in our next Newsletter, another benefit for the members of SMG. Thank you all for your questions, thank you, again, Dr. Yu, for your time, expertise, and great information and help to all of the participants.

genevieveyu [2012/01/23 21:59:33]: Genevieve Yu, M.D.

genevieveyu [2012/01/23 22:00:06]: 16300 Sand Canyon Avenue, Suite 911, Irvine CA 92618Phone 949.333.0446 - Fax 949.529.2566www.GenevieveYuMD.com

loispw [2012/01/23 22:00:22]: Thank you for your valuable information

genevieveyu [2012/01/23 22:00:28]: www.occhildpsychiatry.com