Tourette's Syndrome

Tourette's syndrome (TS) is a neuropsychiatric disorder of childhood characterized by motor and vocal tics that have been present for at least one year. Tics are defined as sudden, repetitive, stereotypic movements and vocalizations that are classified as simple (those that are rapid and appear to have no purpose) or complex (those that are slower, more orchestrated, and appear as if they do have some purpose). Common motor tics include eye blinking, facial grimacing, neck and shoulder movements, and tensing of muscles [Page 572]of the abdomen and limbs. Common vocal tics include sniffing, snorting, and throat clearing. In some cases, syllables, words, and phrases are repeated. Contrary to popular belief, only approximately 10% of individuals with TS have coprolalia (i.e., swearing).

The onset of tics is generally around the ages of five to seven years. Initial tics are simple in form and may gradually progress in complexity. In fact, it is unusual to have complex tics without having simple tics, either concurrently or in the past. Motor tics usually precede vocal tics, beginning in the facial area and progressing from the head downward. However, not everyone with TS has this presentation. In relatively mild cases of TS, the individual may have only some facial tics and simple vocal tics that do not progress in severity or complexity. Tics tend to occur in bouts and tend to wax and wane over time. Between the ages of 9 and 12 years, tics peak in frequency, intensity, and complexity, with occasional periods of significant exacerbation of symptoms. For most children, tics begin to subside in adolescence; approximately 65% of affected children will no longer have tics in adulthood.

Many tics are preceded by a “premonitory urge” to make the tic, in much the same way people experience an urge before a sneeze. Other tics, particularly simple tics such as eye blinking, just happen without warning, as with a hiccup. Also, the urges may be more generalized and experienced as a feeling of inner tension, which is considered more bothersome than the tic itself. One of the most troublesome aspects of TS has to do with the idea of volitional behavior. Because tics can sometimes be suppressed, people may believe that a child should be able to control the tic behavior at all times. Understanding that a tic is a response to an irresistible urge may help people to appreciate that, although the tic itself may be somewhat voluntary, the urge is not and the presence of the urge without being able to respond to it can create intolerable tension.

In school, the most interfering aspect of tics may be the energy a child exerts to stifle the tics, making the child appear as if he or she is not paying attention. Hence, it is important to determine the primary cause of inattention, as this has specific treatment implications, both pharmacologically and behaviorally. Children with TS also have visual–motor integration problems that may impact their school performance, particularly in the area of handwriting. Finally, the tics themselves may cause significant impairment in academic functioning. Eye-rolling tics can interfere with reading, and arm and hand tics can interfere with writing. Vocal tics can be disruptive to the child experiencing them and to teachers and classmates.

...