Students with Tourette Syndrome, Obsessive/Compulsive Disorder (Bipolar), and

Attention Deficit Hyperactivity Disorder

 

Tourette Syndrome

Tourette Syndrome (TS) is a neurological disorder characterized by tics - "involuntary," rapid, sudden movements that occur repeatedly in the same way. To receive a diagnosis of TS a person must have both multiple motor and one or more vocal tics, not necessarily simultaneously, throughout a span of more than one year. The tics may occur many times a day (usually in bouts) nearly every day or intermittently. Tics periodically change in the number, frequency, type and location and wax and wane in their severity. Symptoms can sometimes disappear for weeks or months at a time. While most persons with TS have some control over their symptoms from seconds to hours at a time, suppressing them may merely postpone more severe outbursts. Tics are experienced as irresistible and (as the urge to sneeze) eventually must be expressed. Tics increase as a result of tension or stress and decrease with relaxation or concentration on an absorbing task.

 

Other symptoms include obsessions, compulsions, impulsions, and mood lability.

 

Co-morbid syndromes include Attention-deficit Hyperactivity Disorder, Anxiety Disorders including phobias, Separation Anxiety Disorder, Panic Disorder, and Mood Disorder including Unipolar (depression) and Bipolar (Manic Depression) Affective Disorder.

 

Quick Facts About Tourette Syndrome (TS)

 

·       Tic Disorders appear to be on a spectrum

·       Transient Tic Disorder - Chronic Motor (or Chronic Vocal) Tic Disorder - Tourette Syndrome - Obsessive

·       Compulsive Disorder

·       Prevalence for TS may be 0.1 to 1.0% of the population; for tics, around 20% of the population may have a tic at some time in life

·       the male:female ratio for TS is 3-4:1 (although some of this may be accounted for by referral bias)

·       Diagnostic criteria for TS requires both motor and vocal tics, for over one year's duration, with a waxing and waning course (changes in tic severity and location)

·       Coprolalia (profanity), the most spectacular of the symptoms, is seen in only a minority (from 15-30%) of those with TS

·       Onset of TS is always before age 15; mean age of onset of motor tics is 7; mean onset for vocal tics is 9

 

Motor Tics

 

Simple Motor Tics:

 

eye blinking, eye rolling, squinting, head jerking, facial grimacing, nose-twitching

lip smacking, tongue thrusting, mouth opening, leg jerking, arm flexing or flapping and many others

 

Complex Motor Tics:

 

hitting self or others, jumping, touching self or others, smelling hands or objects, clapping, pinching

touching objects (haphemania), stooping, hopping, kicking, throwing, squating, skipping, somersaulting, stepping backwards, deep knee bending, foot tapping, foot shaking, foot dragging, chewing on clothes, scratching, kissing self or others, pulling at clothes, or about any other combination of movements done repeatedly

 

Vocal Tics

 

Simple Vocal Tics:

 

Throat clearing, grunts, sniffs, snorts, squeaking, coughs, humming, screams, spitting, puffing, sucking inspirations, whistling, honking, stammering or stuttering, hissing, laughing, shouts, barking, moaning, guttural sounds, noisy breathing, gasping, gurgling, squealing, clicking or clacking, hiccups, "tsk" & "pft" noises

 

Complex Vocal Tics:

 

Any understandable words or phrases (may include echoing)

 

Associated Symptoms

 

·       Echolalia (repeating of phrases), immediate or delayed

·       Palallia (repeating words or syllables)

·       Coprolalia (speaking obscenities or socially taboo phrases)

·       Copropraxia (obscene gestures)

·       Stuttering

·       Apraxia (inability to carry out an action, such as reading, without neurological cause)

 

 

 

Attention-Deficit/Hyperactivity Disorder (ADHD)

 

Hyperactivity with or without Attention Deficit disorder (ADHD) occurs in many persons with TS, approximately 60%.  Children may show signs of hyperactivity before TS symptoms appear. Adults may exhibit signs of ADHD such as overly impulsive behavior and concentration difficulties.

 

The cardinal features of ADHD include: poor concentration, impulsivity, and hyperactivity. Subtypes include:

Predominately Inattentive Type, and the Predominately Hyperactive-Impulsive Type.

 

1.Often fidgets with hands or feet or squirms in seat

2.Has difficulty remaining seated when required to do so

3.Is easily distracted

4.Has difficulty waiting turn in games or group activities

5.Often blurts out answers to questions before they have been completed

6.Has difficulty following through on instructions from others

7.Has difficulty sustaining attention in tasks or play activities

8.Often shifts from one uncompleted activity to another

 

Behavioral Concerns

 

·       Quick temper

·       Overaction

·       Mood changes

·       Difficulties with impulse control

·       Oppositional behavior

·       Defiant behavior

 

 

Academic Problems due to Tourette Syndrome Symptoms

 

·       Has difficulty organizing work

·       Has difficulty playing quietly

·       Often talks excessively

·       Often interrupts or intrudes on others

·       Often does not seem to listen to what is being said

·       Often loses things necessary for activities at school or at home

·       Often engages in physically dangerous activities without considering possible consequences

 

Movement and Psychological Definitions:

 

Tics: rapid, repetitive, stereotyped motor movements or vocalizations. Tics run the spectrum from involuntary to more compulsive-like (voluntary); tics can be suppressed, usually abate during sleep. A division occurs into simple and complex tics. There also seem to be "sensory tics."

 

Examples:

·       Simple motor tics: eye blinking, grimacing, puckering

·       Complex motor tics: touching, shouting, combinations of movements

·       Simple vocal tics: barks, coughs, grunts, squeaks

·       Complex vocal tics: words and phrases, coprolalia

 

Obsessions: are stereotyped, irresistible thoughts, ideas, images, that produce anxiety, and are "intrusive" into the patient's thinking. These obsessions are recognized as senseless; also recognized as the person's own thoughts. Attempts are made to suppress and control the obsessions.

 

Examples:

·       contamination - obsessions about germs, chemicals, and other contaminants;

·       disease - obsessions about a skin disorder or AIDS

·       sexual - fears of aggressive sexual impulses towards others or self

·       harm - obsessions about harming self, or others (typically children or spouse)

·       doubting reality - fears of tainted perceptions that may lead to disaster or death, doubting one locked the doors or turned off the stove burners, or fearful one hit a pedestrian

·       "just right" obsessions.

 

Compulsions: voluntary, often irresistible actions/behaviors usually in response to an obsession, that relieves stress or is meant to prevent something bad (like contamination) from happening. The patient recognizes these compulsions as excessive or unreasonable.

 

Examples:

·       skin picking/hair pulling - response to itching or skin obsession;

·       hand washing, wearing gloves - responses to contamination obsessions;

·       touching self, others, or objects - haphemania;

·       checking locks - response to "doubting" obsessions;

·       hoarding objects

·       perfectionistic obsessions.

 

Chorea: quick, irregular movements of extremities (mostly distal); not as stereotyped or repetitive as tics. Choreaform movements are associated with caudate degeneration or inflammation.

 

Examples:

Sydenham's Chorea;

Huntington's Chorea

 

 

Athetosis: writhing, twisting movements of extremities.

 

Examples:

Huntington's Disease;

Wilson's Disease (hepatocerebral degeneration).

 

Tremor: rapid rhythmic vacillating movements of limbs.

 

Examples:

pill rolling tremor at rest (Parkinson's Disease);

essential tremor; (also known as familial tremor)

 

Ballism: rapid thrusting of arm.

 

hemiballism (due to countra-lateral subthalamic damage)

 

Dystonia: sustained spasm of muscle contractions; between spasms muscle tone is normal; acutely, often caused by medications: neuroleptics such as Haldol, even Reglan, or Compazine.

 

Example:

torsion dystonia

 

Myoclonus: sudden fast muscle movements; groups of muscles.

 

Example:

myoclonic jerks during sleep; (caused by tricylic antidepressants)

 

Dyskinesias: generic term for abnormal movements.

 

Examples:

Tardive Dyskinesia: oral-boccofacial movements seen with neuroleptic use (Haldol); can be tic-like, or produce tremors;

Acute dyskinesias;

Extrapyramidal movements such as torticollus, oculo-gyric crisis, Parkinsonian movements, akathesia (restlessness)

 

Self-injury (self-abuse): self inflicted injuries including lacerations, bruises (needle sticks, etc); range from wrist cutting, to skin/scab/nose picking; instrument injury; genital mutilation; head banging.

Examples:

 

·       head banging (Autism, Tourette's, Mental Retardation);

·       skin picking (OCD);

·       self-inflicted infections (Personality Disorders, Factitious Disorder - Munchausen's - and Munchausen's by Proxy, malingering)

 

 
Obsessive-Compulsive Disorder

 

 

Obsessions consist of repetitive unwanted or bothersome thoughts. Compulsive and Ritualistic Behaviors are when the person feels that something must be done over and over and/or in a certain way. Research shows 50 to 60% of persons with TS also have Obsessive-Compulsive Disorder (OCD).

 

Obsessions

 

 

Compulsions

 

 

 

 

 

Medical Treatment of Tourette Syndrome

 

 

Abbreviations/Conventions

 

TS = Tourette Syndrome

OCD = Obsessive-Compulsive Disorder

ADHD = Attention-deficit Hyperactivity Disorder

LD = learning disability

 

Medical Treatment of Tics and Movements in TS

 

1.Neuroleptics (Haldol, Orap, Risperdal)

2.Clonidine

3.Serotonin Drugs (Prozac-like); Klonopin (benzodiazapine with 5HT action)

 

Medical Treatment of OCD in TS

 

1.Serotonin Reuptake Inhibitors (SSRI): Prozac, Luvox, Paxil, Zoloft

2.Anafranil (more side-effects)

3.Augment with dopamine agents (Orap) or Klonopin

 

Medical Treatment of Attention Deficit (ADHD) in TS

 

1.Ritalin

2.Tenex, clonidine

3.Tricyclics: imipramine, desipramine, Anafranil (clomimpramine)

 

Other Medication Issues

 

Sensory symptoms

Biochemistry of TS

Environmental factors

Alerts for medication side effects at school

Goals of treatment

 

Medications for Tic Treatment

 

Neuroleptics (Haldol-like drugs)

haloperidol (Haldol), 0.5 mg - 5.0 mg/day

pimozide (Orap), 0.5 mg - 10 mg/day

risperidone (Risperdal), 1.0 - 6.0 mg/day

neuroleptic medication side effects: sedation; weight gain; EPS: muscle spasms, tremors, restlessness; risk of tardive dyskinesia; skin sensitivity; eyesight changes; anxiety; monitor liver, EKG (esp. Orap), EEG

Alpha-adrenergic drugs

gaunfacine (Tenex), 0.5 - 2.0 mg/day

clonidine (Catepres), 0.05 - 0.2 mg/day

Alpha-adrenergic medication side effects: lethargy; drowsiness; deceased blood pressure; EKG changes

 

Medications for obsessive-compulsive (OCD) symptoms in TS

 

Serotonin Reuptake Inhibitors (SRIs, SSRIs)

Prozac, Zoloft, Paxil, Luvox

Very good for OCD & depression

SSRI side effects: gastrointestinal symptoms; restlessness; insomnia; genital-urinary side effects

 

Anafranil (clomipramine, a tricyclic compound) may improve obsessive-compulsive components of TS (also anti-depressant & anti-anxiety medication

Side effects: dry mouth, constipation, urinary problems; skin changes; lower blood pressure; monitor EKG, EEG, and liver

 

Medications for Attention Deficit

 

Ritalin

May not increase tics if used in reasonable dosages; may decrease vocal tics

Improve concentration, impulsivity, hyperactivity

Ritalin side effects: anorexia, insomnia, irritability; gastro-intestinal upset

 

Tricyclics (Anafranil, imipramine etc.)

Improve attention, impulsivity, hyperactivity

Also anti-depressant, anti-anxiety

Tricyclic side effects: dry mouth, constipation, urinary problems; skin changes; lower blood pressure; monitor EKG, EEG, and liver

 

Alpha-drugs

clonidine, Tenex

improves attention

Alpha-adrenergic medication side effects: lethargy; drowsiness; deceased blood pressure; EKG changes

 

Sensory Symptoms

 

"Just right" feeling

Premonitory urge (sensation or pressure immediately before a tic)

Restless Legs Syndrome

Because of these sensations the movements are more like compulsions,

Therefore, many movements are voluntary-like

 

Environmental Factors in Tourette's Syndrome

 

11 factors resulted in decreased symptoms: visits to doctor's office, relaxed reading, talking to friends

17 factors increased the tics: anxiety, emotional trauma, social gatherings

Other factors were neutral

 

School

 

Poor attention in achool may be due to:

 

1.Tic severity

2.Medication

3.Executive dysfunction (cognitive dysfunction)

4.Social consequences of a stigmatizing disorder

5.Coexistent ADHD, OCD or other disorders

 

 

Classroom Modifications for Students with TS, OCD, and ADHD

 

 

Material Presentation

 

 

 

Classroom Environment

 

 

Time Management/Transitions

 

 

 

Math

 

 

 

Grading and Tests

 

 

Behavior

 

 

Reading

 

 

Organization

 

 

·       Blocking: Block assignments into smaller segments

 

·       Cutting/Folding: Cut or fold worksheets into fourths, sixths or eighths and place one problem in each

·       square

 

·       Color-Coding, Highlighting, or Underlining: Emphasize important information on which the student

·       needs to focus

 

·       Hand out written assignments with expected dates of completion typed or written on one corner

 

Handwriting