Tourettes disorder


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  • TOURETTES SYNDROME: definition-(see slide)
  • In most cases teachers did not approach parents about what is happening at school unless there were major behavioral or learning problems. This has meant that often parents are largely unaware of what is going on. Parents are grateful for a teachers interest to discuss their child’s TS. Parents of students with TS want teachers to realize that it is a real condition needing special attention even though it is not obvious, want teachers to be flexible, understand the loss of concentration that comes with TS and the impact this has on their schooling and how they feel about themselves, if their child or another student with TS requests extra time for completing work don’t think that it’s an excuse. Look at it compassionately. Put yourself in their situation. It’s not as straight forward as for a normal child. What’s two or three days more? Encourage students to be positive, ignore tics and realize they have TS before handing down punishments, and understand that they need a bit more one-on-one to help them keep on a level with the classroom.
  • Obsessions: Obsessions are unwanted thoughts or ideas that occur often and persistently and are experienced involuntarily (Mayo Clinic Health Information Website). They appear over and over again and gives the individual a feeling of being out of control. The person doesn’t want to have the ideas and finds them invading, bothersome, and senseless (Obsessive-Compulsive Foundation Website). The individual with OCD recognizes that the obsessions are not imposed from without, instead they are a product of their own mind. The individual tries to ignore or suppress the obsessions (Rapoport, 1990). People with OCD say the symptoms feel like a case of mental hiccups that won’t go away (Obsessive-Compulsive Foundation Website). Compulsions: Compulsions are defined as repetitive, purposeful, intentional behaviors performed in response to an obsession. Many individuals with OCD are not aware of any specific reason for their compulsions. They just know that performing these actions will relieve their anxiety and prevent them from feeling bad (Rapoport, 1990). The person with OCD does not get pleasure from the compulsions, instead they are used to get relief from the discomfort that comes form obsessions (Obsessive-Compulsive Foundation Website).
  • . Compulsions  Compulsions are repetitive behaviors, the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification.  In most cases, the person feels driven to perform the compulsion to reduce the distress that accompanies an obsession, or to prevent some dreaded event or situation.  In some cases, individuals perform rigid or stereotyped acts according to idiosyncratically elaborated rules, without being able to indicate why they are doing them.  By definition, compulsions are either clearly excessive or are not connected in a realistic way with what they are designed to neutralize or prevent.  The most common compulsions involve washing and cleaning, counting, checking, requesting or demanding assurances, repeating actions, and ordering. (Alarcon 1991) . Obsessions  Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress.  The most common obsessions are repeated thoughts about contamination, repeated doubts, a need to have things in a particular order, aggressive or horrific impulses, and sexual imagery.  The thoughts, impulses, or images are not simply excessive worries about real-life problems and are unlikely to be related to a real-life problem.
  • Boys more likely to have tics, and girls to have OC symptoms; but both can have any of the symptoms of TS (Note: main reason for including it as a separate subtype is the co-occurrence of TS symptoms with other SEH disorders; With co-occurring ADD or ADHD, symptoms of attention disorders often appear before motor or vocal tics do. MEDS for ADHD can actually make tics worse or hasten their appearance. But there are some that can be used--discuss later AGRRESSION- connection between TS and aggression is not yet clear but may have to do with difficulty regulating aggression (aggression also occurs more frequently in TS if already have hyperactivity, impulsivity, or ADD)
  • DSM-IV: Differential Diagnosis= involves comparing child’s behavior with the behavior of children with other disorders that might produce the same symptoms. A way of ruling out what disorders child does NOT have, and determining what disorder he does have. -may rule out head trauma, brain tumors, epilepsy, autistic disorders, muscular dytrophy or transient tic disorder( occurs less that 12 consecutive months), cerebral palsy, Parkinson’s disease-- A Pediatric Neurologist (medical doctor specializing in diagnosing and treating neurological disorders in children) or a Neuro-Psychiatrist ( also knows about OCD, depression, bi-polar disorders, ADHD-and more familiar with medications used to treat associated difficluties) may help with diagnosis.
  • Tic suppression requires much energy and can cause stress which may interfere with a student’s ability to concentrate on classroom tasks. Peers negative responses to tics can cause anxiety, which in turn increase tics and generate self-doubt. Even if a teacher is accepting of tics, students may still try to suppress tics because of concern for unwanted reactions from peers. Children with Tourettes are not usually disruptive students but can be labeled as naughty and weird.
  • Accommodate to students individual needs. A learning plan should consider the many dimensions of TS, including the physical, social-emotional, medical, and psychological needs. Collaborate with children, parents, teachers, and sometimes counselors. Parental involvement is usually highly desired, although this can be difficult for parents. Parental stress associated with dealing with schools, usually for modifying for their child, are reported. Since the syndrome causes excessive movement, interruptions, tension and pain, it makes simple routine activities like reading and writing more difficult (Robertson and Baron-Cohen, 1998) Frustration is another problem for children with TS and some emotional difficulties, such as anxiety and depression (Bruun and Bruun, 1994). Because of all this, it is hard for these students to make friends.
  • Recent research using the Positron Emission Tomography (PET) scan of the brain has shown that the brain patterns of a patients suffering from OCD are different than those seen with other disorders and mental illnesses. This bears out to show that possibly OCD is caused by a neurobiological malfunction involving the brains use of the neurotransmitter Serotonin (Sourcebook, p 279). As with any physical illness and or mental illness treatment should be sought as soon as the disorder is noticeable. The sooner the better is a phrase that applies. This can prevent the OCD from reaching a severe level of dysfunction if treatment is sought and followed through. It is extremely difficult for person’s with OCD to admit they have a problem, because in the early stages it can be ignored by the patient or passed of as this is no big deal. Then, later in life it becomes a big deal and they may be so embarrassed that they do not seek help (Griest,1990). According to the DSM-IV, a specifier can be added to the diagnosis when the patient does not recognize the obsession or the compulsion as excessive or unreasonable (p 419).
  • Tourettes disorder

    2. 2. •Do you know what is Tourette’s Disorder? •Do you know anyone with this disorder?
    3. 3. Origin of the Disorder LabelOrigin of the Disorder Label • Itard – Physician in 1825 – Observed client with tics & copralalia • Gilles de la Tourette – Physician in 1885 – Wrote first detailed reports on disorder
    4. 4. Zentall 2004 4 TOURETTE SYNDROME • a physical disorder of the brain which causes involuntary movements (motor tics) and involuntary vocalizations (vocal tics) • Prevalence: 1 in 2,500 people in US • Boys outnumber girls 3 to 1 • Tics – begin before age 21 (typically around age 7) – change in location, frequency, severity – last a lifetime – must be present for at least a year for diagnosis – other symptoms may also be present
    5. 5. TICS MOVEMENTS • Tics are involuntary, sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations.
    6. 6. Zentall 2004 6 EXAMPLES OF TICS • MOTOR: Simple: blinking eyes jerking neck shrugging shoulders flipping head kicking tensing muscles sticking tongue out finger movements • MOTOR: Complex: facial gestures (eye rolling) grooming behaviors smelling things touching jumping hitting biting echopraxia copropraxia self-injurious behaviors
    7. 7. Zentall 2004 7 EXAMPLES OF TICS • VOCAL: Simple: throat-clearing sniffing coughing grunting spitting yelling belching • VOCAL: Complex: animal sounds repeating words or phrases out of context coprolalia palilalia echolalia
    8. 8. • Coprolalia is the use of obscene words or phrases. • Echolalia is the repetition of the last-heard words of others. • Palilalia is the repetition of one’s own words.
    9. 9. 4 TYPES OF TIC DISORDERS • Tourette’s Disorder • Transient Tic Disorder • Chronic Motor or Vocal Tic Disorders • Tic Disorder not otherwise specified.
    10. 10. Excitation or Inhibition? Brain Region? Neurotransmitters? Nature or Nurture?
    11. 11. Zentall 2004 11 WARNING SIGNS • Most develop – eye tic first – facial tics or involuntary sounds – others within weeks or months • common examples: head jerks, grimaces, hand-to-face movements • Symptoms can: – change over time – vary (frequency, type, or intensity) – increase in intensity during early adolescence (12-15) – improve in less extreme cases during adulthood
    12. 12. • Tourette’s Disorder was 1st decribed in a patient in 1885 by George Gilles de la Tourette. • He noted several similar symptoms among several patients and these symptoms included multiple motor tics, coprolia, palilalia, and echolalia.
    13. 13. PREVALENCE • The lifetime prevalence of Tourette’s Disorder is estimated to be 4 to 5 persons per 10,000 people.
    14. 14. AGE GROUP • This disorder occurs by the age 7 and vocal tics emerge at age 11. • This disorder occurs about 3 times more often in boys than girls.
    15. 15. 15 Children’s Quotes • “I was devastated when I found out I had TS. I thought I was going to be a normal boy. But I’m not. My life is awful. I feel like I’m missing out on a lot of things because of my tics. I will feel a lot better if my tics go. If they don’t I will learn to put up with them.” (Neil, 9yrs) • “I used to get asked why I blinked all the time and everyone used to get angry at me because I couldn’t help looking at them and I always get harassed.” • “My teacher treats me like an angel and manages my TS really well. The other students try to be understanding as my teacher has told them all about TS.” (Neil, 9yrs) • Lyle who is 9 years has Aspergergs and TS, and says he feels like he’s in prison when he is at school.
    16. 16. DISORDER ASSOCIATION • There’s a relation between Tourette’s disorder, ADHD( attention deficit hyperactivity disorder) and OCD (Obsessive Compulsive Disorder).
    17. 17. Zentall 2004 17 Symptoms • Obsessions (thoughts) • Compulsions (actions and rituals)
    18. 18. Zentall 2004 18 COMPULSIONS OR RITUALS: • Placing objects just right • Touching things • Rechecking • Smelling • Licking • Erasing • Writing and rewriting letters until perfect • Washing hands repeatedly OBSESSIVE THOUGHTS: • Mental echolalia Sexual thoughts • Obscene thoughts Thinking about forbidden actions • Counting or grouping Fear of hurting someone
    20. 20. • 40% of all Tourett’es disorder patients also have OCD.
    21. 21. Excitation or Inhibition? Brain Region? Neurotransmitters? Nature or Nurture?
    22. 22. • Stuttering – abnormal breathing pattern – embarrassing physical characteristics – can substitute more acceptable speech patterns – support groups – periods of fluency • Tourette’s –abnormal breathing pattern –embarrassing tics –can substitute more acceptable tics –support groups –tic free periods subgroup of Touretters who stutter, and stutterers with Tourette’s
    23. 23. CRITERIA FOR TOURETTE’S DISORDER • Multiple motor tics and one or more vocal tics have been present at some time during the illness • Tics occur many times a day, nearly everyday or throughout a period of more than 1 year and they are never tic-free for more than 3 months • The onset is before the age of 18 years
    24. 24. Zentall 2004 24 DSM-IV • onset before age 18 • person has both multiple motor and one or more verbal tics • tics occur many times a day (usually in clusters), nearly every day or intermittently for more than a year --------------------------
    25. 25. CRITERIA • The disturbance is not due to the direct physiological effects of a substance or a general medical condition. » DSM-IV
    26. 26. TREATMENTS • Pharmacological treatments are most effective for Tourette’s disorder, but patients with mild cases may not require medications. Psychotherapy will help patients cope with the symptoms, personality, and behavioral tendencies; however, it is ineffective as a primary treatment.
    27. 27. Zentall 2004 27 Facts • Tics can worsen with the use of caffeinated beverages, cough syrup, recreational drugs and diet medication • Identical twins, whose genes are identical, may have tics that differ in the intensity and frequency. This means that non-genetic factors underlie these differences. (Neuroscience for Kids-Tourette Syndrome.)
    28. 28. Excitation or Inhibition? Brain Region? Neurotransmitters? Nature or Nurture?
    29. 29. SOCIALIZATION • Children with Tourette’s disorder or any tic disorder can be socially strained. • Severe social, academics, and vocational consequences can reap havoc on a child’s social life. • Socialization can be damaged so severe that suicide is contemplated in some cases.
    30. 30. 30 Academics • Normal levels of intelligence • Personal distress • Low self esteem & social problems • School failure • Tics can make simple routine activities difficult - ex. reading & writing • Cause anxiety • Involuntary multiple motor and vocal tics • Obsessive compulsive tendencies • Short attention span / ADD • High anxiety • Learning disabilities
    31. 31. Zentall 2004 31 Treatment Strategies• Provide access to a private room for tension and tic release • Offer short breaks • Break long assignments into smaller parts • Allow movement around the room • Have a rest/safe area- Ex. bean bag chair • Try to ignore tic behaviors that are not seriously disruptive (Wilson, Jeni. Shrimpton, Bradely. Planning Learning for students with Tourette Syndrome. Student Disability Conference, 2003). • Modify abusive vocal tic patterns • Modify socially inappropriate or disruptive vocal tics / noises • Monitor expressive suprasegmentals • Monitor receptive language development and processing (LLD) • Teach good vocal hygiene habits
    32. 32. PROGNOSIS • Tourette’s disorder is usually a chronic, lifelong disease with relative remissions and exacerbations. • Initial symptoms may decrease, persist, or increase, and old symptoms may be replaced by new ones.
    33. 33. PROGNOSIS • Severely afflicted persons may have serious emotional problems, including major depressive disorder. • Some of these difficulties appear to be associated with Tourette’s disorder.
    34. 34. 34 Etiology • Theories or explanations of causes
    35. 35. FACTS OF INTERESTFACTS OF INTEREST • Genetic predisposition – autosomal (non-sex chromosome) dominant – male has 99% chance; female has 70% chance • Incidence – 1 in 2,500 – 3 to 1 male/female • Characteristics fluctuate over time • Onset before age 18; average 7 years
    36. 36. Linkage AnalysisLinkage Analysis • Somatic cells contain paired chromosomes, one from each parent • At gamete formation, paired chromosomes coil around each other and exchange material • Portions of DNA close together tend to be inherited together • Many genes take same form in everyone • Some genes have several different versions (alleles) • Noncoding “junk” DNA can vary considerably between people; can be genetic marker to identify parent DNA
    37. 37. • Genetic investigations have supported the role of both dopamine D4 receptor gene (DRD4) and dopamine transporter gene (DAT1) in the vulnerability to the disorder. • The DRD4 gene has been postulated as a candidate gene for attention-deficit-hyperactivity disorder – Lower DA binding in basal ganglia – Increased DA transport in frontal lobes
    38. 38. Dopamine • Up to 40% of OCD patients do not respond to SSRIs • Cocaine worsens compulsions in Tourette syndrome • Family studies show OCD and Tourettes are linked leading • Use of older antipsychotics that block DA receptors added to ongoing SSRI reduces severity of symptoms in resistant clients (especially those with Tourettes)
    39. 39. genes brainstructure behaviour learning feeling conduct- dyslexia anxiety disorder dyscalculia depression ADHD Autism TD Etc ….. Chemistry : noradrenaline, serotonine, etc
    40. 40. • Tourettes: believed to be caused by abnormally high dopamine levels in some part of brain
    41. 41. MEDICATIONS • Haloperidol is the most frequently prescribed drug for Tourette’s disorder. • As many as 70 to 90% of patient’s symptoms decrease with this drug and this drug is used on 80% of the patients. Tourettes = conventional antipsychotics and SSRIs Haloperidol –somewhat effective –strange side effects: halucinations
    42. 42. SUMMARY COMMENTSSUMMARY COMMENTS • Tourette’s Syndrome difficult to diagnose due to variability of symptoms • Primary intervention in pharmacological treatment; not always accepted by adults due to side effects • Can have significant social, emotional, vocational impact • Team approach with SLP as member
    43. 43. Responsibility to Tourette’s patients • Clinicians should prescribe the proper diagnosis and prognosis to the patient with Touette’s disorder. • Parents should ensure that their child receive proper care for this disorder. • Parents should have open communication with the child(ren) to know what he/she is feeling.