When I see kids who’ve been diagnosed with selective mutism, cognitive behavioral therapy, or CBT, is usually the first treatment that’s recommended. The decision whether to use medication as part of the treatment—and the choice of which medication to use—is made in discussion with parents and the child’s therapist. The use of medications has to be carefully considered and it has to be seen as part of a treatment plan.

So which kids do we think of starting on medication as well as CBT?

First, it’s the older kids—those whose SM has lasted longer. Typically they’re 7 or 8 (or older) instead of 4 or 5, and they’ve been anxious for years now.

Second, medication is indicated for those whose SM is more pervasive. Those who are severely impaired—just not functioning at all well in school or with friends—may need more than behavioral therapy to counter their anxiety.

Third, kids who’ve already had a poor response to behavioral therapy. If a child or a teenager is not meeting CBT benchmarks, sometimes it’s because her anxiety is so great that she can’t even engage with the therapist or the team that’s trying to help her. For those kids you may want to add medication to lower their anxiety, so they can make better use of the CBT, and be able to carry it through to the end.

Fourth, children who have other coexisting psychiatric problems. I have found that a lot of times kids come in with more than one anxiety, so there might be the selective mutism, but it might coexist with phobias, say, or OCD. If I see a child who has anxiety but on top of that there’s depression, or ADHD—the kids that have more than one thing wrapped around together—I might consider moving more quickly to treating them with medications. This is because the medication can help not only with the anxiety, but with depression and other things that are going on.

And last, if there’s a family history of SM, or another anxiety disorder. That would mean that there is a genetic loading for things like anxiety disorders and depression, and a child may need the medication to counter it.

What is the preferred medication for SM? Though you may know them as antidepressants, selective serotonin reuptake inhibitors, or SSRIs, are considered the first-line treatment for anxiety disorders. Over 20 years of research with these medications has shown them to be the best for non-OCD anxiety. Not only do we see kids getting better, we have the data to support what we observe.

I should clarify that the SSRIs do have some effectiveness for OCD anxiety, too, but they’re better on non-OCD anxiety. In fact they work better on anxiety than they do on depression in children, where they’re only modestly successful. SSRIs actually work better in adults than kids, because I think there’s a shift in the nervous system in adolescence. But in terms of non-OCD anxiety, which includes selective mutism, these medicines are extremely effective with very, very low side effects.

Roy Boorady is a child and adolescent psychiatrist and the senior director of the Psychopharmacology Service at the Child Mind Institute.

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