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| Division of Occupational Therapy - OT Connect Tourette's Syndrome
Gilles de la Tourette syndrome (TS) is a pervasive disorder affecting neurologic and behavioral function (Case-Smith, 2001). Although the basic cause of TS is unknown, current research suggests that there is an abnormality in the gene(s) affecting the brain's metabolism of neurotransmitters such as dopamine, serotonin, and norepinephrine. Neurotransmitters are chemicals in the brain that carry signals from one nerve cell to another. It is estimated that 100,000 Americans have full-blown TS, and that perhaps as many as 1 in 200 show a partial expression of the disorder (National Institute of Neurological Disorders and Stroke, 2001). Diagnostic Criteria: (Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV)
Common Symptoms/Course of Disease Most characteristic of TS are involuntary vocal and motor tics. (Case-Smith, 2001). Vocal Tics include:
Motor Tics include:
(National Institute of Neurological Disorders and Stroke, 2001). Tics alternately increase and decrease in severity, and periodically change in number, frequency, type, and location. Symptoms may subside for weeks or months at a time, but later can recur. People with TS can sometimes suppress their tics for a short time, but the effort is similar to that of holding back a sneeze. Eventually tension mounts to the point where the tic escapes. Tics worsen in stressful situations; however they improve when the person is relaxed or absorbed in an activity. In most cases tics subside during sleep (National Institute of Neurological Disorders and Stroke, 2001). Diagnoses associated with TS: Not all people with TS have disorders other than tics. However, many people experience additional problems such as obsessive compulsive behavior, characterized by an intense need to act repeatedly, such as hand washing or checking that a door is locked; attention deficit-hyperactivity disorder, characterized by difficulty concentrating and staying on task; learning disabilities, which include reading, writing, and arithmetic difficulties; or sleep disorders, which include frequent awakenings or talking in one's sleep (National Institute of Neurological Disorders and Stroke, 2001). Age of Onset: Symptoms of TS generally appear before the individual is 18 years old (National Institute of Neurological Disorders and Stroke, 2001). Symptoms of the condition usually appear in middle childhood, worsen for about 10 years, then lessen somewhat. The symptoms usually continue through the individual’s lifetime, with some periods of remission (Case-Smith, 2001). Sex Bias: TS occurs more frequently in boys than girls (Case-Smith, 2001). Males are affected 3 to 4 times more often than females (Tourette Syndrome Association, Inc., 2004). Cultural Bias: TS can affect people of all ethnic groups (National Institute of Neurological Disorders and Stroke, 2001). Current Medical Treatment: There is no cure for TS. Most people with TS do not require medication, but medication is available to help when symptoms interfere with functioning. TS medications are only able to help reduce specific symptoms. Some patients who require medication to reduce the frequency and intensity of the tic symptoms may be treated with neuroleptic drugs such as haloperidol and pimozide. These medications are usually given in very small doses that are increased slowly until the best possible balance between symptoms and side effects is achieved. Recently scientists have discovered that long-term use of neuroleptic drugs may cause an involuntary movement disorder called tardive dyskinesia. However, this condition usually disappears when medication is discontinued. Short-term side effects of haloperidol and pimozide include muscular rigidity, drooling, tremor, lack of facial expression, slow movement, and restlessness. These side effects can be reduced by drugs commonly used to treat Parkinson's disease. Other side effects such as fatigue, depression, anxiety, weight gain, and difficulties in thinking clearly may be more troublesome. Clonidine, an antihypertensive drug, is also used in the treatment of tics. Studies show that it is more effective in reducing motor tics than reducing vocal tics. Fatigue, dry mouth, irritability, dizziness, headache, and insomnia are common side effects associated with clonidine use. Fluphenazine and clonazepam may also be prescribed to help control tic symptoms. Medications are also available to treat some of the associated behavioral disorders. Stimulants such as methyphenidate, pemoline, and dextroamphetamine, usually prescribed for attention deficit-hyperactivity disorders, although somewhat effective, have also been reported to increase tics; therefore their use is controversial. For obsessive compulsive behaviors that significantly disrupt daily functioning, fluoxetine, clomipramine, sertraline, and paroxetine may be prescribed. Other types of therapy may also be helpful. Although psychological problems do not cause TS, psychotherapy may help the person better cope with the disorder and deal with the secondary social and emotional problems that sometimes occur. Psychotherapy does not help suppress the patient's tics. Relaxation techniques and biofeedback may be useful in alleviating stress which can lead to an increase in tic symptoms. (National Institute of Neurological Disorders and Stroke, 2001) Occupational Therapy Involvement The occupational therapist (OT) must fully examine a child’s specific developmental skills, and how their performance is influenced by the physical and social demands of the home, school, and community environments. After identifying the functional activities most important to the child and the child’s caregivers, the OT evaluates the components of the child’s development that are necessary for the child’s participation in everyday childhood occupations. Priorities of the family and child are a necessary part in the intervention planning process. When deciding how therapy services will be provided, it is important to consider other services the child is receiving, medical and educational concerns, and financial, transportation, and scheduling constraints. In order for a treatment program to be successful, the child’s strengths and needs in the context of the environmental demands, child and family priorities, and funding considerations must be considered. Specific areas of intervention for the child with TS are:
(Case-Smith, 2001) It is important that the student with TS is able to function in the classroom. The OT can educate the child’s teacher on classroom adaptations for the child with TS: For tic symptoms
For fine/motor visual impairment
For obsessive compulsive symptoms
For short fuse difficulties
For ADHD symptoms
(Tourette Syndrome Association, Inc., 2004) References
How OT Makes a Difference: Evidence-Based Practice School based occupational therapy services for children with Tourette’s Syndrome Packer, L., & Gentile, M. (1994). School based occupational therapy services for children with Tourette Syndrome. Advance for Occupational Therapists, 10, 16. Classroom seating for children with attention deficit hyperactivity disorder: therapy balls versus chairs. Schilling, D., Washington, K., Billingsley F., & Deitz, J. (2003). Classroom seating for children with attention deficit hyperactivity disorder: therapy ball versus chairs. American Journal of Occupational Therapy, 57, 534-41. The use of a weighted vest to increase on-task behavior in children with attention difficulties. VandenBerg, N. (2001). The use of a weighted vest to increase on-task behavior in children with attention difficulties. American Journal of Occupational Therapy, 55, 621-8. Mike is a 10 year old boy diagnosed with Tourette syndrome (TS), obsessive-compulsive disorder (OCD), sensory integration dysfunction (SID), attention deficit hyperactivity disorder (ADHD), and anxiety disorder. Just 5 months ago, he was diagnosed with TS; however, he has been receiving outpatient Occupational Therapy (OT) services since he was 7 years old for OCD, SID, and ADHD. Before being diagnosed with TS, it was unknown if his tics were obsessive behaviors, or actually tics. Mike has several vocal tics, including barnyard noises. Fortunately, Mike does not experience coprolalia (shouting obscene words), but he is overly anxious of the possibility of this occurring. He also has several motor tics, including facial, head, and body movements. This is Mike’s first year in the public school setting. He had attended a private Christian school previously where the students and teachers were like a family and excepted Mike for who he was. Mike has a hard time dealing with change. With his family preparing to move next year, Mike was placed in a public school to slowly expose him to changes. They are hoping that by moving him to a new school this year, he will be able to adjust easily to another new school after they move. He is also involved in the academically gifted program, which takes place on full school day a week. Mike is still receiving outpatient OT services. His family opted for him to not receive OT in the school system. They didn’t want him to be removed from the classroom more than is needed, and they didn’t want him to be labeled as being different. The OT introduced the Wilbarger Protocol to Mike and his family. This involves brushing the child and providing joint compressions every 2 hours. Mike and his family were compliant, and performed this procedure over the summer. Mike responded well to this treatment, with a noted decrease in sensory defensiveness. The OT also addressed fine motor skills and hand tasks. Mike had problems with his handgrip, due to sensory issues and muscle tightness in the hand. The OT helped Mike with hand extension, having him write on windows and other vertical surfaces. Mike still fatigues easily, however writing has gotten drastically easier for him. The OT also spoke to Mike’s teacher about his problems with handwriting. He is now only required to write 75% of the writing expected in the classroom. Mike also has been educated on TS, and has learned to recognize the emergence of tics, helping him to better control them. Mike’s teacher has been very cooperative with the OT recommendations. His teacher sends him on make-believe errands that involves going up and down stairs, while he wears a weighted backpack with sand. This “wears his body out,” and relaxes him before exams. Mike’s mother said that OT has helped Mike in so many ways, and she is so grateful for everything the OT has done for him.
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