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  • Lora Lee

Selective mutism requires personalised care

My son is 13. He has been a selective mute for three years, and was diagnosed with attention deficit disorder (ADD), even though he can pay attention to subjects he is interested in. Do you think medication would help to manage his attention and anxiety so that he can talk in school?

I understand how frustrating and worrying this must be. But before you rush into medication and treatment, it is vital to understand that ADD does not really concern an inability to pay attention. It's more about attention inconsistency and excess energy. Both this and selective mutism are complex conditions and need the support of mental health professionals. So here I outline what you should pay attention to when seeking treatment support.

"The hallmark symptoms of attention deficit disorder are easy distractibility, impulsivity and sometimes, but not always, hyperactivity or excess energy," note psychiatrists Edward Hallowell and John Ratey in their book, Driven to Distraction (2011). Brain disorder specialist Daniel Amen points out there are about seven types of ADD and each responds to different medication and treatments. From my clinical experience, children affected by selective mutism often also have anxious attention deficit disorder or limbic attention deficit disorder.

Both are very different from the classic ADD, and other types of the disorder.

In a brain scan, limbic attention deficit disorder shows an overactive limbic system in the brain, and anxious attention deficit disorder shows overactivity in the basal ganglia area. That is the opposite of most types, where those regions of the brain tend to have decreased activity. Before I can answer whether medication would help, it is vital to know which type affects your son.

ADD stimulants on their own might increase your son's anxiety level and not help his recovery in treatment of his selective mutism. You would need a consultation with a psychiatrist to see if you could boost his dopamine levels, and control his anxiety level before any behaviour cognitive therapy could take place effectively. ADD is not a curse - it is a difference that can be worked around. Your son can still be happy, productive and successful if you believe in him and give him the right support.

Selective mutism, often referred to as "social phobia's cousin", is an anxiety disorder in which the phobia of talking prevents children from speaking in certain social situations, such as in school, or in public. It is a complicated topic.

The Diagnostic and Statistical Manual of Mental Disorders estimates that selective mutism affects one in 1,000 children referred for mental health treatment.

Your son is unique and will need intervention that is tailored to his needs and challenges. For example, a child whose selective mutism is brought on by bullying in school will not respond to exposure-based techniques.

The child will need reassurance that the bullying is being dealt with and will need to know how to report and deal with bullying before the child can tackle the selective mutism.

Since your son has remained silent in public for three years and his speech therapy has not been helping, it will take longer to tackle his selective mutism. He is now comfortable not speaking and has likely found other ways to communicate.

The stepladder approach (a form of exposure-based practice) is often used, together with social skills training, to help children build resilience to face what they fear in a systematic and manageable way.

One of the advantages of the stepladder approach is that it involves everyone, including the parents and the school. This way, the school can see that steps are being taken and be sure that the child is receiving appropriate treatment.

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