Tourettes
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Tics, most commonly present in Tourettes syndrome, are recurrent intermittent compulsive movements that involve a particular muscle group. Tourettes syndrome, otherwise known as Gilles de la Tourette, is a neurobiological childhood condition characterized by motor and phonic tics that change over time. These motor and phonic tics wax and wane in severity and usually decrease in frequency and severity by early adulthood (Murray, 1997). The purpose of this paper is to describe tics as characterized by Tourettes syndrome (TS), including the behavioral, social, and emotional implications of the disorder.
According to the DSM-IV (American Psychiatric Association, 1994), the essential features of TS are the presence of multiple motor tics and one or more vocal tic that occurs several times a day, recurrently throughout a period of more than one year. These symptoms cause distress or significant impairment in social, occupational, or other essential areas of functioning (????).The estimated prevalence rates for TS in the general population varies from four to five per 10,000 people with a 3:1 increased tendency in males to females. Age of onset of tics is between 2-15 years of age (DSM-IV, 1994).
Tics can be defined as visible, sudden, repetitive, stereotyped motor movements or phonic productions that involve one or more muscle group (Leckman, 2002). Although tics are classified as involuntary movements, many individuals with TS report that tics are voluntary responses to involuntary sensations (Corbett et al., 1969). Tics are commonly classified as simple or complex. Some examples of common simple tics are, eye blinking, shoulder jerking, grunting, throat clearing, barking, and sniffing. Some examples of common complex tics are, facial grimacing, arm flapping, coprolalia (the involuntary use of obscene words), palilalia (the involuntary repetition of ones own words or phrases), echolalia (the involuntary repetition of anothers words or phrases), and echopraxia (the involuntary imitation of the movements of others). Despite the fact that coprolalia is one of the most well known symptoms of TS, it affects only small percentage of individuals with the condition and it is not required for diagnosis (Goldberg, et al., 1994).
Many of the symptoms of TS can be alleviated with various forms of psychotropic medications, however symptoms cannot be eliminated. TS is most commonly treated pharmacologically with haloperidol (Snyder et al., 1970). The goal of treating TS with medication is to use the lowest dose possible to decrease the target symptom to an acceptable level while enhancing the childs development (Bagheri, et al., 1999).
Although many children are able to suppress their tics for a period of time, a sensational urge remains until the tic is eventually released. Some children are able to suppress their tics for an entire school day and consequently engage in releasing tics for several hours at home (Leckman, 2002). ). Tics may be exacerbated by stressful situations, emotional excitement (Robertson, 2000), anxiety, physical exertion and may be present during sleep and during sexual arousal (OQuinn and Thompson, 1980). TS is often accompanied by psychiatric, behavioral, and developmental disorders.
TS has several associated conditions such as, attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), language and learning disorders, anxiety disorders, mood disorders, stuttering, addictive behaviors, aggression, inappropriate sexual behaviors, and sleeping difficulties (??????). Some of the behavioral problems that present with TS are short attention span, restlessness, compulsivity, difficulty concentrating, poor impulse control, and low frustration tolerance (OQuinn and Thompson, 1980).
(???More???) Other than motor and phonic tics, ADHD is the most common symptom of TS (Comings, 1990). Children with ADHD exhibit developmentally inappropriate levels of inattention, impulsivity, and overactivity (Sherman et al, 1998). ADHD and symptoms associated with ADHD can occur in 30-90% of children with TS. According to Peterson et al., the epidemiological evidence for an underlying linkage between TS and ADHD is unclear (2001).
OCD is a behavioral disorder characterized by obsessions, compulsions, and ritualistic actions. Other than motor and phonic tics and ADHD, OCD behaviors are the most common symptoms found in TS (Comings, 1990). OCD has been found in 20-60% of children with TS who are referred to clinics (Coffey and Park, 1997). Some researchers have found parallels between the sensory urges that cause tics and the cognitive urges that cause OCD (Coffey & Park, 1997). Children with both TS and OCD tend to have symptoms related to ordering, counting, rubbing, touching, evening up, and symmetry. Contamination fears and repetitive hand washing are also common in children with both TS and OCD. It is also reported that children with both tics and OCD may have more aggression and demonstrate sexual obsessions as compared to those without a tic disorder (Coffey & Park, 1997).
Although language and communication disorders are not commonly recognized by clinicians as an associated feature of TS, speech and language abnormalities are commonly reported among the TS population (Comings, 1990). Children with TS may present with word finding problems, poor language expression, rushes of speech, unintelligible speech, and echolalia (OQuinn and Thompson, 1980) and dysfluency. Individuals with TS may demonstrate fluency failures in their speech (Van Borsel and Vanryckeghem, 2000), however not all researchers are in agreement that the dysfluencies are synonymous with “stuttering”. Fluency difficulties commonly present in individuals with TS include repetitions, hesitations, false starts (OQuinn and Thompson, 1980) and “stutter-like behavior” (Singer, et al., 1978).
Children with TS are more likely to require educational support than the typical child without TS. It is important to note that most children with TS have a normal IQ and cognition (Murray, 1997). Although tics are not directly related to learning disabilities, they may interfere with function in school. Arm tics may adversely affect handwriting, and eye tics or head tics may interfere with literacy (Packer, 1997). Concentration may also be disturbed because great effort is often necessary to suppress tics and the tics can often distract the child from the classroom focus. Children with TS often have dysgraphia and visual-motor integration problems which, affects handwritten work, copying from the blackboard and computer skills (Packer, 1997). Some suggest that the learning difficulties associated with TS should be attributed to comorbid ADHD (Murray, 1997).
Tics typically have the greatest effect on an individuals self-esteem