Tourette Syndrome (TS) and Tic Disorders

Introduction

• Tourette syndrome (TS) is a neurological disorder characterized by sudden, repetitive, rapid, and unwanted movements or vocal sounds (tics).
• TS is considered a tic disorder.
• There is no cure for TS, but treatments can help to manage symptoms.
• People with TS often have a normal life expectancy.¹ 

Causes

• The cause of Tourette’s Syndrome is unknown.
• It may be linked to the part of the brain that regulates body movements.
• Boys are more likely to be affected by TS than girls.² 
• There is likely to be involvement of gene variations and environmental factors.

Co-occurring Conditions

• Attention Deficit Hyperactivity Disorder
• Obsessive-Compulsive Disorder or Behaviors
• Anxiety
• Learning Disabilities
• Behavioral issues
• Insomnia
• Social functioning difficulties
• Sensory processing issues related to touch, taste, smells, sounds, or movement¹ 

Tics

• Tics can come and go.
• Tics are not degenerative.
• Tics may also vary in type, frequency, location, and severity.
• People first experience symptoms from 5-10 years.
• The progression is often from the head to the trunk then arms and legs.
• Tic symptoms are often worse in the early teens.
• Tics can last into adulthood.
• Tics may worsen in adulthood.
• Treatment is not needed if symptoms do not interfere with daily life.

Simple Tics

• Sudden, brief, repetitive movements of muscle groups.
• More common.
• Eye blinking
• Facial grimacing
• Shoulder shrugging
• Head or shoulder jerking

Complex Tics

• Distinct coordinated patterns of movement involving several muscle groups.
• Less common.
• Facial grimacing combined with head twists and shoulder shrugs.
• Sniffing or touching objects.
• Hopping, jumping, bending, or twisting.

Vocal Tics

Simple Vocal Tics

• Repetitive throat clearing, sniffing, barking, or grunting sounds.

Complex Vocal Tics

• Repeating own or other’s (echolalia) words or phrases.
• Vulgar, obscene, or swear words (coprolalia) – rare.¹ 

Tic Triggers

• Excitement
• Anxiety
• Physical factors, e.g., too tight of a collar
• Environmental factors, e.g., hearing another person sniff or clear their throat¹ 

Diagnosis

1. Presence of both motor and vocal tics that occur several times a day, every day or intermittently for at least 1 year.
2. Onset of tics before age 18.
3. Tics not caused by medications, other substances, or medical conditions.¹ 

Outcome Measures

• Yale Global Tic Severity Scale³ 

Occupational Impact

• May have learning difficulties and low grades in school.⁴ 
• Children with TS were rated by teachers as having ‘major’ learning difficulties.⁵ 
• Children in a study experienced impaired concentration and attention.⁶ 
• There may be delays in academic skills such as handwriting, word retrieval, and visual image memory, and grammar.^7 8 
• Behavior problems may exacerbate learning difficulties in school and affect peer interactions negatively.⁶ 

Occupational Therapy Treatment

• Tics may interfere with children’s ability to perform their daily occupations.
• OTs work with children (and adults) who have limitations or interruptions in their daily activities or occupations.
• Most OTs will treat children with tics using a sensory approach, but
• A sensory approach may be slower at producing results compared to other behavioral therapies.
• In conjunction with medications, clients may receive non-pharmacological treatments.⁹ 
• Collaborative models and tools such as a daily report card system or token economies can enhance learning and improve behavioral strategies.¹⁰ 
• Habit reversal training (HRT)
  • May lead to a reduction in tic severity in children aged 9-13 years.
  • Clients develop an awareness of when tics are about to occur and then develops a behavior to stop the tic when the urge to tic arises.
  • HRT has been developed into a Comprehensive Behavioral Intervention for Tics (CBIT).¹¹ 
• Comprehensive Behavior Intervention for Tics (CBIT) is an 8-10 week treatment program 1x/week.
  • CBIT has been shown to reduce the number of tic expressions, severity, and psychological level of distress associated with tics. It improved children’s self-perception of their competence in performing everyday activities.¹² 
  • As tics may be sensitive to the environment, people can use CBIT to learn factors that trigger their tics and learn to calm their tics.
  • 87% of CBIT participants continued to do well 6 months post treatment.
  • While CBIT is not a cure, it can be a useful management strategy.¹³ 
  • Children learn to become more aware of their tics and their triggers.
  • Children develop and practice “competing” behaviors when feeling the urge to tic
  • Children learn new strategies and responses to better manage their tic disorder in their daily activities.
  • Requires practice outside of the treatment in other environments.¹⁴ 
• Exposure with response prevention (ERP) involves clients suppressing their tics for prolonged periods of time and beginning to habituate to them and reduce the urges to produce tics.
  • Found to be equally effective as HRT/CBIT, but long-term effects are not established in one study.
  • ERP clients may receive 2x the therapy as HRT.¹⁵ 
• Supportive psychotherapy/CBT/Assertiveness training may serve as complementary therapies but are not effective by themselves.¹⁶ 
• Address anxiety and emotional symptoms.
• Educate teachers and parents about the syndrome.¹⁷ 
• Promote a school environment that is safe with rules and expectations that are predictable, but flexible to adjust to specific learning problems.^18 8 
  • Allow students to sit on the side of the classroom.
  • Headsets may help increase attention span.
  • Change tasks frequently.
  • Use color coding and highlighting with small manageable sections for schoolwork.^{19 20 21 22} 
• Assist educators and families to determine which strategies are most likely to be successful academically.^7 23 
  • Avoid expressing frustration, anger, or negative reactions.
  • Consider providing students with breaks for short periods to release the tics they have been suppressing.
  • Educate peers about the syndrome so that they become more tolerant and supportive as well as ignoring possible tic disturbances.²⁴ 
  • Group work may help children with TS to understand and manage their condition by practicing social interactions with peers.²⁵ 
• Students endorsed assistive technology such as computers, calculators, and spell-checkers for schoolwork.
• Students also welcomed accommodations such as extra time in class, not having too much homework, receiving feedback for improvement, and not being punished for their TS behaviors which may result in reduced anxiety.¹⁷ 

Classroom Strategies and Accommodations

• Ignore the tics
• Permission to leave the room as needed
• Preferential seating
• Extended time for assignments and tests
• Word processors, Calculators, Scribe, Tape recorders, Books on tape
• Testing in a separate location
• Reduced homework
• Reduced amount of handwritten work assignments
• Permission to eat lunch somewhere else
• Leaving class early to avoid hallway congestion²⁶ 

Bookmark

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3. Wilhelm, S., Peterson, A. L., Piacentini, J., Woods, D. W., Deckersbach, T., Sukhodolsky, D. G., … & Scahill, L. (2012). Randomized trial of behavior therapy for adults with Tourette syndrome. Archives of general psychiatry, 69(8), 795-803.[↩]
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9. Rowe, J. (2017). Benefits of Occupational Therapy for Tourette Syndrome. Retrieved from https://tourette.org/benefits-occupational-therapy-tourette/[↩]
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11. Yates, R., Edwards, K., King, J., Luzon, O., Evangeli, M., Stark, D., … & Murphy, T. (2016). Habit reversal training and educational group treatments for children with tourette syndrome: a preliminary randomised controlled trial. Behaviour research and therapy, 80, 43-50.[↩]
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17. Hollis, C., Pennant, M., Cuenca, J., Glazebrook, C., Kendall, T., Whittington, C., … & Stern, J. (2016). Clinical effectiveness and patient perspectives of different treatment strategies for tics in children and adolescents with Tourette syndrome: a systematic review and qualitative analysis. Health Technology Assessment (Winchester, England), 20(4), 1-450.[↩][↩]
18. Dornbush MP. The Neuropsychological Functioning of School-age Children with Tourette Syndrome. Unpublished Doctoral Dissertation, Georgia State University, USA, 1984[↩]
19. Clarke MA. A School-Based Intervention Designed To Reduce The Frequency Of Tics In Children With Tourette Syndrome. Unpublished Doctoral Dissertation, University of Connecticut, USA 1997.[↩]
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