CHAPTER 8
Is Medication Helpful in
Selective Mutism?
One Family’s Experience and a Clinical Overview
This chapter charts the progress of Simon (not his real name) in his journey to overcome Selective Mutism (SM). An attempt has been made to give as complete a picture as possible of the challenges faced by families raising a child with such special needs. It describes Simon’s development of SM and how his family tried to come to terms with its effects and finally to find a way out of its more debilitating aspects. The broader issue of medication is also discussed.
Early years: birth to 2 years
Simon was born in 1996, the third child of a family that was, eventually, to grow to four with the arrival of a brother in 1997. Two older children were aged 12 and 9 at his birth. At the time Simon was born, the family lived and worked in Hungary as part of a teacher education scheme set up by the British Council. The older children were attending local primary schools and were completely bilingual. Both parents were fluent in Hungarian, though languages were kept reasonably distinct. The language of the home was English and that of school Hungarian. Simon was brought up speaking English and was surrounded, largely, by English-speaking people.
Simon’s first two years were unremarkable. His mother looked after him at home. Having two older siblings ensured a lot of contact with other children. His early development followed a normal trajectory, although Simon was thought to have a much greater, and earlier, awareness of his surroundings than had been the case with his brother and sister. He seemed to be able to concentrate for longer, and more intently, than other children. At the age of two he would sit in front of Disney films for almost their entire duration without, apparently, getting distracted.
He was an early talker. At the time of John’s birth he was already using multiple words and expressing himself clearly. In fact, his development of language seemed to be accelerated. It quickly became clear that the family as a whole needed to be careful what was said in his presence in case unwelcome repetitions occurred at inopportune moments. This is common for all parents, but what seemed to be different with Simon was his ability to focus on, and make some sense of, things that were going on around him but that were not specifically directed at him. On one occasion the family were watching a particularly bloody episode of Casualty on TV, when someone noticed that Simon had taken up distressed residence behind the sofa. For some years after this he would get hysterical at the sight of blood, particularly his own.
Trauma: age 2 years 4 months
Simon appeared to be a particularly sensitive person. One particular event stands out as a trigger for a whole raft of behaviours that would seem to directly lead to his SM.
The family holiday that year took them to the south of France and a meeting with three families, two of whom were seen regularly on trips home from Hungary. The other, the family of the father’s brother, was seen less often. Since everyone was approaching the final destination from different directions it was agreed to meet at a campsite en route. Simon’s family arrived first. The brother, who has a certain family resemblance to the father despite being three years younger, arrived a little later. They met up on one of the many campsite paths connecting tents and wash areas. Simon and his sister Jane (not her real name) had gone on ahead and came upon her uncle who had come looking for them. On seeing him, Simon ran into his arms and allowed himself to be thrown up in the air. It was only when he got a closer look that he realized the man who had hold of him was not his father but a strange man whom he did not know. He became hysterical and for the rest of the holiday (two weeks) lost his appetite and would not let any close member of the family out of his sight.
Pre-school, Hungary: ages 2 years 4 months to 4 years 4 months
On return to Hungary, Simon’s mother was taking up a new six-month part-time appointment which entailed putting both Simon and John into a kindergarten. This is quite common in Hungary and facilities are generally excellent so there was no concern, even though he did not speak Hungarian. When the family had first arrived in Hungary the elder children had learned the language by doing this. However, Simon was different. He did not settle and made no effort to play with other children or speak the language.
It became clear that Simon had become increasingly agitated by the company of anyone who was not a close friend or family. If anyone visited the home, he would run away and hide, and if it was in the street, he would studiously avoid any sort of eye contact. It was not completely obvious that he had stopped talking altogether and, since a lot of friends were Hungarian, he could speak safely in the knowledge that it was only his family who could understand him.
However, it was on occasions when the family returned to the UK for family holidays that it became clear that Simon’s difficulty in coping with anything out of the ordinary, particularly new people, was not normal, and not something that could simply be explained away by excessive shyness. The family would arrive home and it would take him at least two days before he would talk to his grandparents. Similarly, with each visit to close friends, it would take longer for him to settle in their company and engage in conversation. He stopped talking in the earshot of anyone with whom he was not familiar. Shopping was a nightmare, and fittings for new shoes nearly impossible.
The significance of this kind of behaviour was downplayed by the family, but there were times when it became impossible to ignore. On one occasion Simon got separated from the family and was discovered by a concerned passer-by. She explained that she had been at a loss to know what to do because she couldn’t get any information about who he was and where his parents were.
Primary school, UK: ages 4 years 6 months to 5 years 6 months – SM in the school
The family returned to Britain full-time in 2001. Simon had gone to a number of kindergartens in Hungary but had not made any effort to interact with the other children. He would talk to his parents in front of other children and teachers at school but never to them directly, even if they spoke some English. It was not that he had never shown any desire to socialize with other children. He had made close friends with a number of English children and, having overcome his initial ‘shyness’ when returning home for holidays, he would happily join in games with children of close friends. Sadly, the problem turned out to be more serious than expected.
Simon started school at a small local primary school whose intake in the year that he joined was just four children. One of the boys joining the class – a boy called Chris – lived in the same village and appeared to have similar interests, although all attempts to introduce them to each other at village events over the preceding summer had met with failure. Simon had studiously rejected any suggestions of a get-together.
The task of taking him to school for the first time was left to his father. After lengthy discussions involving parents and the school it was felt that the presence of his mother might make it more, not less, difficult for him to get used to being left at school. Various methods at the different kindergartens he had gone to in Hungary had been tried (all of them involving staged withdrawal after varying lengths of time – some stretching to weeks). None of them had been particularly successful. Painful though it may be, it was decided this time to try the ‘short sharp shock’. His father accompanied him into his classroom but quickly made excuses and left him with the teaching assistant and teacher, making it clear that there was always the telephone if he didn’t calm down. He was picked up from school at the end of the day and the parents were told that Simon had cried solidly for nearly two hours. The school had been about to make contact when he calmed down enough to stop. He hadn’t spoken to anyone at school but at this stage this wasn’t the issue. After all, it was reasoned, he had been too upset to do so.
Over the next few weeks, Simon slowly improved when being left – that is to say he stopped crying – but he would not speak to anyone within the school environment. However, he did show some interest in getting to know Chris this time. On a trip to the local cinema he finally said something. His classmate’s amazement was such that he didn’t reply to Simon but looked at the rest of the family and said: ‘Did you hear that? Did you hear that? Simon spoke.’ After this Simon continued to speak to Chris outside of school and as long as he knew no one else from the school was listening. To a certain extent Chris became Simon’s interpreter, being able to decipher the sign language and grunts that Simon used to communicate in the school playground. In the classroom it was different. Simon remained completely silent. As he learned to write he was given a white board and was able to write answers to class questions on this, but he would not speak.
Later, another child from Simon’s class moved into the village and Simon was able to talk in front of her at home. The number of children Simon would speak to outside school rose to three, as new year groups joined Simon’s, but this was where it stayed. Attempts were made to get Simon to speak to them on his own at school – when all the teachers and staff had gone – hoping that if he could hear his own voice at school when speaking in a non-threatening environment, he would be less ‘afraid’ of using it in front of others. Unfortunately, this never looked like becoming a useful strategy.
Obviously, Simon’s behaviour caused considerable alarm both to his family and to the school. It wasn’t long before steps were taken to seek medical intervention and consider issuing a statement of special needs in education. As anyone who has gone through this procedure will know, this is a very lengthy, bureaucratic and time-consuming business for parents. Eventually, Simon was referred both to the local educational psychologist and a child psychologist. After some time, Simon did feel able to speak in front of her. At least this enabled her to begin a diagnosis of his condition; above all, to establish whether his SM might be related to other problems of social anxiety or to investigate whether he might also fall on the autistic spectrum.
Simon’s parents reported intense feelings of hopelessness. No one seemed to have had anything more than an incidental awareness of this kind of problem. Simon was referred to the Speech and Language Therapy department of the LEA and an advisor was appointed to work alongside Simon once a fortnight for an hour. At a loss to know how to proceed, the newly trained therapist asked the parents for advice. The suggestion was made of establishing a relationship through playing board games (in a separate room made available at the school). For the next year Simon was taken out of classes but there was no discernible improvement beyond an increased ability to succeed at card games: a wasteful indication that practitioner education in the matter of SM is essential.
Their sense of desperation at the lack of progress from the school and medical authorities eventually led the family to explore alternative treatment and research the condition more widely themselves. The following account is a breakdown of the different approaches that they tried during Simon’s years at primary school. Most of these came about as a result of information provided by the charity Selective Mutism Information & Research Association (SMIRA), which was contacted after a search on the internet.
Primary school: ages 5 to 11
The work of Maggie Johnson and her co-author Alison Wintgens on a cognitive behavioural approach to the problem can be found in their extremely practical The Selective Mutism Resource Manual (2001). This was bought by the school as a possible solution to the problems relating to Simon’s treatment. In his second year both the school and the language therapist assigned to Simon tried to introduce some of the stimulus fading techniques – particularly the sliding-in approach. Sadly, there was no real success. It is difficult to decide whether this failed because of a lack of belief, a misunderstanding about how it should be implemented, or simply because in a small school it was impossible to invest in one child the amount of time and effort required for progress.
The child psychologist was very supportive of these efforts and, during the one-to-one therapy sessions, endeavoured to provide Simon with a mechanism to understand his emotions and quantify his fear of speaking on a scale of one to ten. Whilst this did help Simon confront his condition and give him some means to understand the way he was feeling, as far as allowing him to make practical progress in the school there appeared to be no substantive effect.
However, in the absence of any other obvious forms of treatment, a rather haphazard application of these techniques was tried out at the school, combined with regular – if rather infrequent – therapy sessions in the hospital. The latter were mainly geared towards establishing how far Simon could be categorized as belonging to the autistic spectrum.
At the school, Simon’s silence was increasingly accepted as the norm. This meant that he could slip into the background during school work. He continued to use the white board to write answers on during class activities. For reading, the teachers had to rely on reports from the parents although, bizarrely, Simon would ‘read to the teacher’ by audibly mouthing words and indicating intonation patterns in sentences.
Socially, Simon wasn’t exactly isolated. The other school children simply saw him as the child who doesn’t talk. He wasn’t excluded from playground games, but obviously his inability to communicate did not help integration. Periodically, a supply teacher would arrive and see his behaviour as deliberate defiance. On one occasion he was made to stand up in front of his classmates, while the teacher reprimanded him for not talking.
Treatment, during this period, consisted of the occasional initiative (such as personal white boards or pairing him with the one pupil he was known to speak to outside of class, Chris). His mother was also sometimes used as a supply teacher, having qualified as a primary teacher. None of these approaches seemed to have any noticeable effect. However, there were a few bright moments (whispering out of earshot, in a different room, to Chris) but nothing that could really qualify as a breakthrough or be regarded as lasting in any sense.
Ages 9 to 11: drug intervention – medication and its immediate aftermath
In the face of this lack of progress, and aware that his condition was likely to be an increasing problem for his educational development beyond primary school, his parents applied themselves to researching alternative forms of treatment. One approach that seemed to be shunned in the UK, but which was common practice in the USA, was the use of anti-depressant drugs and in particular the use of fluoxetine (commonly known by its trade name, Prozac). It was thus timely when a TV company approached SMIRA for volunteers on a documentary they were seeking to do on SM. They explained that they were looking to follow two children through a course of treatment: one taking the behavioural therapy route, the other medication. Simon was keen to be involved, partly because he recognized the kudos of being filmed for TV and partly because he saw medication as a possible magic bullet, solving all his problems in one go (RDF Media – Help me to Speak 2006).
A request was made to his psychologist to see whether such treatment might be tried out in his case. Whilst not being a particular supporter of the medication route, his psychologist felt that in this case, especially since Simon was enthusiastic to try it, there was merit in giving it a go as long as it was properly supervised by a trained psychiatrist whom she had already identified.
The involvement of the TV company was also considered important since it was clear that Simon saw this as having high cachet value as far as his peers were concerned. The hope was that it would boost his self-esteem as much as the medication would. The filming was a very low-key affair with only two people involved in interviewing and camera work. They worked hard to establish a relationship with Simon, and interviewed family and professionals (both educational and medical) to get a picture of how the condition had affected all concerned. Simon responded well and was prepared to talk, however minimally, about his feelings on camera. Filming at school illustrated the extent of his problems and the various coping mechanisms he, his classmates and the school used to try and overcome communication difficulties. There was a particularly revealing moment when Simon explained how he felt when being surprised by someone he identified with school at a church event where he was talking normally. ‘As soon as I saw him, I felt as though I had been betrayed.’ That he had somehow violated his personal space.
The treatment with fluoxetine began after an initial consultation with the psychiatrist and an explanation of the possible side-effects and risks. On the kind of low dosage that would be used with an eight-year-old these were not particularly frightening. Treatment would begin with a daily dose of 2.5ml which would be increased to 5ml gradually unless there were unpleasant reactions. The theory was that since fluoxetine increases the uptake of naturally produced serotonin, the drug can help to reduce inhibition in children.
The results, whilst not spectacular, were noticeable. Simon seemed to be visibly more relaxed when approached by strangers. He overcame his reluctance to speak to shop assistants and did not hide when visitors came to the house. He was much more care-free, less reticent, when playing games with Chris. However, at school there was little change, though perhaps more willingness to communicate through signing and a greater desire to join in playground football games. Indeed, one of the supply teachers tried to take advantage of this by making him captain of the school football team for one match. As an interview in the film demonstrates, this provoked an acknowledgement of how important verbal communication is on the football field, but also an insight into how (in his own mind) he was able to overcome it by a complicated series of hand signals. As far as classroom work was concerned, he remained locked in silence.
The most dramatic result of the treatment came after approximately six months when the parents encouraged him to invite a group of school friends around for his birthday party which would consist of a game of five-a-side football. Amongst those invited were at least three children who he had never spoken in front of. The day came and, true to his word, as soon as he opened the door on them, he began speaking as though there had never been an issue. On the football field, for the first time he was able to shout ‘pass, shoot, give it to me, tackle’ where before he had simply mouthed the words. There was a clear feeling of liberation, and as far as these children were concerned – as long as they were nowhere near the school – he was no longer affected by SM when he was with them after this day. However, the school remained a major sticking point. He wouldn’t talk on the school premises.
Simon carried on taking the fluoxetine, under supervision, with regular (monthly) sessions with the psychiatrist until the start of the summer holidays (in total for around nine months), when he decided that he would like to give it a rest for a while.
He declined to go back on it when he returned to school after the summer holiday. To a certain extent, this would be a litmus test for the long-term effect that the drug (or the accompanying film) had had on his condition.
There was no doubt that he was much more confident at school, although perhaps this was a result of seniority. Simon was now in Year 6. He still did not speak in class but there were rare occasions when he was observed to whisper something in the playground to his group of friends. This situation remained for the rest of his time at primary school.
However, there were some major developments in other areas. At the beginning of the new school year his mother was able to spend a little more time at the school. She would go into class and take out a group of children to do work on a group and individual level. The idea was to select children who Simon had spoken to outside of school in the hope that they would make him feel more comfortable. At first it didn’t seem to help, but after about four weeks Simon began to speak and by the end of this period he was even having to be told to shut up. Whilst, as mentioned above, this did not translate to the rest of the school, it was still a significant development which demonstrated to him that speaking in the school environment was possible after all.
This was particularly important since he was in the process of choosing his secondary school and it was clear that his initial reaction to that school would play a big role in determining whether he carried his SM with him or left it at the gates of his primary school. There were a number of factors that seemed crucial as far as this decision was concerned. He didn’t want to go to a school where a lot of his fellow classmates would be going. He had set his sights on going to a school which one of his best friends already attended. His parents arranged a meeting with the Head Teacher and head of year, to plan a staged transition for him. It appears that at this meeting Simon managed to speak to the Head in his office. He was also able to speak when attending the various introductory days organized for new pupils at the school.
Outside of the school environment he had also become more confident. He was able to speak to the vicar during Confirmation classes, even though there were other children (from different primary schools) present during these sessions.
The fact that all of these developments came about after he had stopped his treatment with fluoxetine suggests that the gains made while on it – confidence and assurance – were not completely lost. That does not mean to say there were not any setbacks. At football practice one morning he phoned home, in some distress, to ask to be fetched early. He appears to have had some sort of panic attack triggered by feeling sick. The same thing happened at a local Valentine’s Day party when his favourite song was played over the sound system.
Secondary school: ages 11 to 15
Overall, the transition to secondary school and his ability to take part in lessons was remarkably painless given the difficulties he had experienced with all other starts in his education. The fact that he was going to a school of his choice with people he wanted to be with, and having made a conscious decision that it was going to be different, seems to have emboldened him. Whilst he will never come across as the most garrulous of students, he can at least function in a modern communicative classroom. This ability, however, perhaps disguises some more lasting issues that it is easy to overlook when one sees how far he has come.
He still is prone to panic attacks. These seem to manifest themselves when he feels he is unable to control his emotions, or be in control of events. For example, a visit to the York dungeons with a friend resulted in him having to leave; a trip to a local football match where a seat behind a goal left him feeling vulnerable to misdirected shots; going to parties where he might not know everyone. He has a tendency to get rather obsessed by certain things, or routines.
Set against this there are numerous successes. His ability to focus has turned him into a very good drummer and he even played in a band at his sister’s wedding. He has been on a variety of school trips with no problems. He has a good circle of friends and seems to be able to fit in with his peer group. For example, he doesn’t ever seem to have been affected by bullying. He can now talk to his teachers in class. Those who have no knowledge of his past find it difficult to believe that he didn’t speak at all in primary school.
There is no doubt that Simon has been on a very definite journey with his SM. It is difficult to say whether it has been completely conquered or removed. It is more that, as he has grown, he has been able to develop certain coping mechanisms that allow him to function in society. There are circumstances when his natural reaction is to try to avoid unsettling situations. This can make him over-cautious and, in a school environment, retiring. However, if the rewards are there for him, he has a clear determination to make sure that he can reach them.
The role of fluoxetine
On the face of it there seems little doubt that the decision to try fluoxetine to reduce his anxiety was the right one. As Maggie Johnson has said, it should never be seen as a complete panacea, but it can help to create the conditions where progress can begin to be made. Simon had no real side-effects from the drug apart from occasional sweatiness at night, and he only ever took small doses – 5ml was the maximum. It didn’t seem to deaden emotions in the way that other users sometimes describe. If anything, the tendency to lessen inhibitions meant that it was necessary for his parents to keep a watchful eye on over-boisterous behaviour. As Simon said, it seemed to give him a window onto a world free from the paralyzing constraints of social anxiety.
However, important as fluoxetine was, the whole experience of being filmed for TV and being the centre of attention in a non-threatening way was equally significant. This enabled him to be more comfortable in himself, which in turn has allowed him to open out and express himself.
Conclusion
Simon has now reached the stage where his SM – in its severe form – is largely confined to the past. He can cope with strangers at home and outside. He remains undemonstrative and certainly too self-aware for his own good, but he is learning to exercise some control over the anxiety levels which enforce this. It is important to keep an open mind about the effect his medication had on his journey, but there is no denying that it coincided with a gradual improvement in his condition. Above all, it would appear to be a valuable addition to the full range of treatment that is available to sufferers of SM. Simon’s example, and the journey his family have been through as a result of it, is surely a testament to the need for flexibility in the face of a condition that is, in itself, so inflexible.
Comment
The remainder of this chapter has been contributed by Dr David Bramble, in his capacity as a child psychiatrist.
This account of Simon’s life to date illustrates perfectly the challenge posed to families and health, educational and other specialist professionals when confronted by such case-complexity. After what appears to be two years of essentially normal development, Simon changed, and his habitual communication and social interactive styles particularly so. These concerns were picked up, as is usually the case, first by his parents and were shared by the nursery staff and his first teachers subsequently. The picture of articulate, middle-class parents seemingly moving heaven and earth in order to make full use of what resources were available to get to the bottom of their son’s difficulties and then address them really early on in his life is very familiar to clinicians working in the fields of neurodisability and paediatric mental health. In Simon’s case, his extremely handicapping shyness and highly selective communicative style were also associated with marked situational anxiety (which occasionally progressed to full-blown panic attacks) as well as some features suggestive of accompanying autistic traits, but the results of any subsequent investigation or help on this score are not presented.
From the perspective of medical treatment, the fact that the boy was evidently experiencing severe and handicapping degrees of anxiety was acknowledged and the environmental, educational and behavioural management strategies available for him were attempted before medication was considered. This general approach, with a few exceptions, is axiomatic in modern paediatric mental health practice and particularly when helping children with anxiety-related disorders. However, when these approaches were found wanting, the selection of a form of medication that is regarded as a standard treatment for chronic anxiety in older adolescents and adults was prescribed, and to good effect. Sometimes, in order to bring about symptomatic relief rapidly before the fluoxetine normally begins to work (four to six weeks) another type of medication, diazepam, may be used.
Simon took fluoxetine for nine months in his late childhood and it was acknowledged that it was more than likely that this specifically helped him make a step-change in terms of mastering his SM symptoms by relieving his situational anxiety and enhancing his confidence, notwithstanding his evidently relished novel role as the subject of a television programme! These benefits were accrued without the troublesome side-effects that are often experienced when this form of treatment is prescribed. Medication, when used in this way, commonly complements other therapeutic and special educational measures.
Despite not taking fluoxetine over the period, Simon’s transition to secondary school went reasonably well even though this represents a period of heightened anxiety and uncertainty for many anxiety-prone children and particularly so for autistic children. It was interesting to note that Simon’s confidence and ability to communicate clearly and authoritatively was reportedly particularly evident whilst he was playing football, and serves to emphasize how team-based exercise coupled with a sense of shared purpose (i.e. sport) can temporarily override inhibiting degrees of anxiety. Physical fitness per se is very important in promoting confidence in children with anxiety-related problems.
General information on medication and SM
Whilst defined as a distinct anxiety-based disorder in the latest editions of the major disease classification systems, SM may be seen to represent a relatively uncommon ‘final common pathway’ of expression of a range of paediatric mental health and developmental problems and also commonly overlaps with several other discrete conditions where handicapping anxiety and social phobia are prominent (Kopp and Gillberg 1997; Kristensen 2000). This heterogeneity of aetiologies (causes) and associations will help explain why, to date, no large-scale controlled clinical trials of any form of drug treatment have been conducted specifically for SM. Rather, the extant literature rests upon small studies involving single cases, case series (Carlson et al. 1999) and small controlled studies of patients with SM whose handicapping anxieties were sufficiently severe and unresponsive to other measures as to merit a trial of drug therapy (Black and Uhde 1994). Nevertheless, what is emerging from this is the wider recognition that classes of drug that relieve handicapping anxiety tend to work best in helping patients with SM master their situationally specific social communication difficulties.
It is axiomatic in British child mental health practice that treatment is very rarely primarily drug-based; rather, targeted medication is best applied as part of an integrated, multi-modal therapeutic package which is tailored to the needs of individual children. Furthermore, in potentially long-term conditions such as SM, as the child matures such treatment commonly has to be adjusted to meet changing needs.
Modern clinical practice also requires that formal ‘care plans’ are elaborated in order to ensure that everyone involved in the child’s care knows what their roles are and what individual objectives they have to work towards so as to avoid any potential confusion or duplication of effort.
So in the case of SM where non-pharmacological, psychological, speech and language therapy and educational measures are either not working or are only partially effective through the presence of handicapping degrees of anxiety for any given individual, and after specific anxiety-reducing psychological therapies (such as relaxation and cognitive behavioural therapy) have been tried, consideration of anxiety-reducing medication is commonly the next step. It must be emphasized that drug therapy is not always necessary and tends to be reserved for older children and adolescents, and those with more severe and pervasive difficulties – that is, difficulty speaking in all major life settings – and those with handicapping associated mental health difficulties, or ‘co-morbidities’, such as depression, panic disorder and obsessive compulsive disorder. Furthermore, the child who is also autistic tends to require more physical treatment of this sort.
Types of medication
Modern paediatric psychopharmacology now has a wide range of agents to draw from, but in the case of treating handicapping anxiety two broad classes are used in everyday practice: benzodiazepines and selective serotonin re-uptake inhibitors (SSRIs).
1.Benzodiazepines. The most common agent used in this group is diazepam (‘Valium’), which has been available for 50 years; another popular drug in this class is lorazepam. These agents provide rapid reduction in anxiety by enhancing the action of a brain chemical called GABA. In short-term use they are generally safe and effective and work quickly (within an hour of ingestion) but are not recommended for long-term use because they can produce tolerance (i.e. higher doses required to produce the desired effect) and dependence (i.e. a need to continue to avoid unpleasant withdrawal symptoms); this is why it is recommended that they are used only for a few weeks if taken regularly (i.e. every day). Most commonly, they are prescribed to be used on an intermittent basis and in anticipation of particularly anxiety-provoking situations (e.g. exam vivas, public speaking, acting or singing performances) or as a temporary measure on a regular daily basis before SSRIs start working in patients experiencing chronic and handicapping anxiety (see next section). Whilst generally regarded as being a rather safe medication, benzodiazepines can, very occasionally, produce paradoxical effects which include irresponsible behaviour, aggression or even delirium (a temporary confusional state). Another important consideration when using this class of drug is that they are known to inhibit learning through interference with memory formation; therefore, if taken for longer periods they may counter or interfere with remedial educational or psychotherapeutic measures the child is also receiving. Patients with breathing difficulties such as sleep apnoea and chronic bronchitis should not take these drugs because they can potentially severely aggravate these conditions. Dosages are usually low (1 to 2mg twice to three times a day) and a liquid version is also available. For situational anxiety, higher single doses may be required. It is recommended that patients do not take this medication regularly for more than four to six weeks.
2.SSRIs. A particularly well-known example of this class of agent is fluoxetine hydrochloride (‘Prozac’); whilst it was developed 40 years ago to be a safe and effective anti-depressant medication and is now the most commonly prescribed drug for this condition in the world, subsequent research and clinical experience has demonstrated that it is also a very effective means of treating generalized and chronic anxiety. However, unlike the benzodiazepines, this treatment usually takes several weeks to exert its therapeutic effects (normally 6–8 weeks) and can produce more, although mostly mild, side-effects. SSRIs are generally alerting (or wakefulness-promoting) drugs; therefore, they tend to be taken as a single dose in the morning. They have a long duration of action so that an occasional missed dose will normally not be noticed in terms of a rapid return of anxiety, and sometimes they are taken every other day. Whilst precisely how they exert their anxiety-reducing effect is not fully understood, they are known to boost the brain chemical serotonin which is the principal moderator of mood in certain parts of the brain and also promote the growth of mood-enhancing brain cells in specific brain areas such as the hippocampus. Fluoxetine is generally well tolerated, although mild side-effects such as nausea, blurred vision, constipation or diarrhoea are relatively common but short-lived; in older patients the drug is known to reduce sex drive and can induce insomnia. The latter condition may be prevented by giving the drug as a single dose in the morning (the usual regimen). Commonly employed dosages are 20 to 40mg a day, although lower initial doses are used with younger patients and higher doses in older patients particularly where obsessional and compulsive symptoms are also prominent. A typical trial of this treatment is two to three months and, if shown to be both effective and well tolerated (i.e. not producing uncomfortable serious side-effects) by this time, then it is continued up to six months at which point, and if there isn’t a pressing reason not to, a staged withdrawal over a month is undertaken to test ongoing need. Should the handicapping anxiety return and if all other non-drug supportive measures remain in place, then the drug is recommenced and taken for another year. Over this time the child should be reviewed every few months to check compliance, emergence of side-effects or for dose adjustment. Other drugs in this class are citalopram and sertraline, which may be substituted for fluoxetine.
Antihistamines and buspirone may be used in a similar, short-term or prophylactic way as diazepam. The anti-depressant drug venlafaxine that enhances the effects of both serotonin and noradrenaline in the brain may be used as a long-term treatment when the SSRIs prove ineffective. The anti-epilepsy drug pregabalin is also used as a second-choice treatment of generalized anxiety in adults but has not been studied in children or adolescents for this indication.
Other considerations
Whilst a particular medication might appear objectively entirely suitable for a particular patient, there may be resistance to taking it encountered from the family and the child. These considerations should be addressed in a sensitive manner and it may take a while to gain the trust required to try it. There are also families where a wait-and-see approach is appropriate because rapid changes in symptoms can occur over a modest time period. Some people may not be able to swallow tablets or do not tolerate the taste of particular liquid forms of the chosen drug, so awareness of alternative preparations (such as taste-neutral drops) may be preferred. Any patient taking medication for mental heath problems should be reviewed regularly (but not necessarily frequently) and screened for compliance, treatment response and emerging side-effects.
Summary
Whilst medication does not ‘cure’ SM, it can significantly relieve the associated anxiety and also ameliorate other co-morbidities so as to help ‘jump start’ children to begin to gain greater benefit from psycho-educational measures which are commonly used to treat the condition. Any trial of medication should be under the supervision of a clinician with appropriate experience of both SM and paediatric psychopharmacology who is also prepared to work collaboratively with all other professionals involved in a given case and also ensure that any other co-morbidities present are also addressed satisfactorily.