Tourette Syndrome can range from mild to severe symptoms, affecting about six in every 1000 people. Oftentimes, a child is not particularly bothered by their tics. However, what can be very distressing to the individual are the associated problems of TS: inattentiveness, hyperactivity, impulsivity, obsessions, compulsions, anxiety, or learning problems. Thus, it is important to be evaluated by a health care professional who is skilled in diagnosing tics and TS who understands the biological causes and mimickers of tics, and appreciates the associated disorders of TS.

Comprehensive Evaluations

An initial evaluation for a child or adolescent with possible tics or TS begins with a comprehensive medical history and physical/neurological examination. Often a child is successful at suppressing his tics during an office visit. We may not “see” what you describe. It can be helpful to bring video of your child or observations noted by his teacher. From the information provided, our experienced clinical staff can usually classify the type of tics and behavioral manifestations. There is no laboratory or imaging test that is diagnostic of TS. However, in atypical presentations, these tests may be recommended to rule out other disorders, or there may be testing for allergies that can mimic tics, such as repetitive “sniffing” or “throat clearing”.

Individualized Treatment

Treatment will depend upon the outcome of the comprehensive initial evaluation. Treatment will be tailored to the severity of your child’s symptoms. Often, it is not the tics but the associated behavioral symptoms that cause the most impairment and require intervention. Thus, if a child has simple motor tics that are not causing distress, we may recommend no treatment and take a “watch and wait” approach.
Sometimes, if a child is made more aware of his tics he can actually gain some conscious control over them. This has led to behavioral interventions for tics and TS. “Habit reversal” is a behavioral treatment for tics. It involves awareness, relaxation, and competing response training in which the patient is taught a specific response pattern that would be physically incompatible with the targeted tic. For example, if the tic manifests as head jerking backwards, the patient is taught to contract the neck flexors with the chin down and in when there is an urge to tic. Research has shown that comprehensive behavioral intervention for tics (CBIT) therapy can be very effective. Other behavioral therapies such as biofeedback have not been shown to reduce tics. Cognitive behavioral (“talk therapy”) or other supportive therapies may help a child deal with feelings of distress or social isolation related to tics.
Sometimes medication is recommended along with behavioral treatment. At CNNH, medications is prescribed conservatively and usually after behavioral approaches are not fully effective. Several different types of medication have been found to be effective in reducing tic severity. Alpha-adrenergic agonists such as clonidine or guanfacine are often used first-line because of lower side effect risk compared to other medications. Selective serotonin reuptake inhibitors can help reduce underlying anxiety or obsessive-compulsive symptoms. Neuroleptics are drugs used to treat psychotic disorders but can also suppress tics. However, neuroleptics have potential risks of side effects such as weight gain, metabolic changes or induction of other movement disorders. Overall, when medication is used, it requires careful monitoring by a health care professional experienced in their use. We discuss with families medication options, side effects and benefits versus risks prior to their use.
A common and often debilitating condition that occurs in individuals with TS is attention deficit hyperactivity disorder (ADHD). Like tics, there are ways to treat ADHD without medication, but in some cases medication might be necessary to achieve success. Medication choices for ADHD in those with TS is more complicated, as some medications used to treat ADHD can worsen tics. Your CNNH clinician will be able to discuss this topic further with you and assist you in making optimal treatment decisions.
Comprehensive initial evaluations, pragmatic treatment decisions, continuity of care and access to expert clinicians and therapists are essential in the treatment of TS and tic disorders. Please contact us for additional information, or if you would like to make an appointment.

About TS/Tics

Tourette Syndrome (TS) is a neurological disorder that presents before the age of 18 years. It is characterized by motor and/or vocal tics. Tics are rapid, sudden movements or vocalizations that occur repetitively in a predictable pattern. They are thought to be involuntary, however, a person may have some control over his or her movements. The urge to express the tic increases and eventually the person needs to release it, like an itch that must be scratched.
In the 1880s, the French physician Dr. Georges Gilles de la Tourette described individuals with a syndrome of multiple motor and vocal tics as having a movement disorder, and thus, it is now called Tourette Syndrome in his honor. TS can occur in anyone. Some well-known individuals who have been afflicted with TS include the billionaire Howard Hughes, actor Dan Ackroyd, comedian Howie Mandel, baseball player Jim Eisenreich, and soccer player Tim Howard.
There is some evidence that TS is an inherited disorder. Although a specific gene or set of genes have not yet been identified, it is known that boys are affected much more frequently than girls. Additionally, there is research evidence that there are changes in certain parts of the brain (particularly the basal ganglia and frontal lobes), disorganization in specific brain circuits, and imbalances in chemical messengers such as dopamine.
Tic disorders can be classified according to age of onset, duration of symptoms, severity of symptoms and the types of tics present. Transient tic disorders often begin in early childhood. A tic involving the face, such as eye blinking, usually presents first. Transient tics last a few weeks or months and are not associated with behavioral or learning problems. Tics may increase when a child is excited or stressed. They usually do not last more than a year but may recur. Chronic tic disorders last over many years and the types  and patterns of tics usually do not change.  Thus, most individuals who have tics do not have TS.
TS is characterized by many different types of both motor and phonic (vocal) tics that frequently change and are relatively complex. The diagnostic criteria for TS includes:
1. Both multiple motor tics and one or more vocal tics, although not necessarily concurrently.
2. Tics occurring many times a day nearly every day or intermittently throughout a period of more than one year, and without a tic-free period of more than three consecutive months.
3. The disturbance causes marked distress or significant impairment in social, school, work, family or other important areas of functioning.
4. The onset is before age 18 years.
5. The disturbance is not due to the direct physiological effects of a substance or a general medical condition.
Thus, TS is diagnosed in retrospect after a child or adolescent has had tics for more than a year. Particularly in mild cases, the disorder may go undiagnosed and not recognized until adulthood. Sometimes, the involuntary movements of TS may look like seizures (epilepsy). When a specialist evaluates your child, he or she will decide if further testing is necessary to differentiate motor tics from seizures or other causes. Many children with neurodevelopmental disabilities display a variety of stereotypical (repetitive) behaviors and vocalizations that are similar to what is observed in TS. If involuntary movements start after the age of 18 years, there should be a thorough clinical investigation for movement disorders and diseases other than TS.

Signs and Symptoms

Motor Tics
• Simple motor tics: fast, darting, meaningless movements; includes eye blinking, shoulder shrugging, tensing or jerking of any body part
• Complex motor tics: slower, stereotypical (predictable) series of movements such as hopping, clapping, twirling, touching things or people, copraxia (obscene gestures), echopraxia (imitating movements of other people)

Vocal Tics

• Simple vocal tics: meaningless sounds and noises; includes coughing, barking, grunting, and single syllable sounds such as “eee.”
• Complex vocal tics: meaningful utterances such as words or phrases, interruptions in the flow of speech, or sudden alterations in pitch or volume; “oh boy,” “wow,” copralalia (socially unacceptable words or phrases), palilalia (repeating one’s own words), echolalia (repeating sounds of others).

Behavioral Manifestations

• Attention Deficit Hyperactivity Disorder: a common neurobehavioral disorder characterized by inattentiveness, hyperactivity, and/or impulsivity.
• Obsessions: preoccupation with a fixed idea or an unwanted feeling or emotion, often accompanied by symptoms of anxiety.
• Compulsions: an inner drive that causes a person to perform actions, often of a trivial and repetitive nature, against her or her will.
• Emotional liability: excessive emotional reactions and frequent mood changes.
• Irritability
• Impulsivity
• Aggressive behavior
• Self-injurious behaviors
• Learning disabilities
• Social difficulties

Symptoms can present as mild, moderate, or severe in their frequency, complexity, and how much they interfere with the individual’s daily life. Symptoms may wax and wane, come and go, and change over time. Tics may increase or occur in bursts at times of excitement or stress, such as holidays. Generally, symptoms begin to decrease during adolescence, although there can be persistence and worsening during adulthood.

“Using information they obtained from my son’s medical history, learning and thinking styles, and specialized brain and genetic testing, the CNNH team was able to “think outside the box” and prescribe a comprehensive treatment plan that really works, both at home and in school!”

— Jamie C.

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