PMH/501 Week 7: Neurodevelopmental and Childhood-Onset Disorders, sample paper

Blinking, Sniffing and a Grunt in Class: Diagnosing Tourette Syndrome in a 9-Year-Old, Rating Tic Severity and Choosing Behavioral Therapy First

[Student Name]

University of Phoenix

PMH/501: Neuropsychiatric Disorders

Week 7 Assignment

[Instructor Name]

[Date]

The child and family are composites written for a model paper.

Ethan, a 9-year-old third grader, comes with his parents. For about 18 months he has had repetitive eye blinking, then shoulder shrugging and nose wrinkling, and for the past year sniffing and occasional grunting. The tics change over time and worsen with excitement or fatigue. He says he feels an itchy urge before a tic and can hold it back briefly, but then it "has to come out." A classmate has begun to tease him. His father had eye blinking as a child. This paper describes the evaluation.

Tics and Their Features

Tics are sudden, rapid, recurrent, nonrhythmic movements or vocalizations. Simple motor tics include blinking and shrugging; simple vocal tics include sniffing and grunting. Many people with tics experience a premonitory urge, a sensation that is relieved by the tic, and can suppress tics briefly. Tics typically wax and wane and change in type over time.

Applying DSM Criteria

Tourette syndrome requires both multiple motor tics and one or more vocal tics at some time during the illness, not necessarily concurrently; tics that may wax and wane but have persisted more than one year since first onset; onset before age 18; and no attribution to a substance or another medical condition. Ethan has multiple motor tics and two vocal tics, persisting 18 months, beginning at 7. He meets criteria.

Rating Severity

Leckman et al. (1989) developed the Yale Global Tic Severity Scale, a clinician-rated instrument scoring number, frequency, intensity, complexity and interference for motor and vocal tics, with a separate impairment rating, and showed it to be reliable and valid. Ethan's total tic score is 22 of 50, moderate, with impairment rated 20 because of teasing and embarrassment.

The tics were not the whole problem; the teasing, the attention in class and the worry at home were part of what the scale had to measure.

Co-Occurring Conditions

Tourette syndrome commonly co-occurs with ADHD and OCD, which often cause more impairment than the tics. I obtain Vanderbilt rating scales from parents and teacher, which are negative for ADHD, and ask about obsessions and compulsions; Ethan reports needing to touch things an even number of times, which bothers him mildly. I also screen for anxiety and mood problems.

Other Explanations

Stereotypies are rhythmic, often begin earlier and lack a premonitory urge. Sudden onset of tics with OCD symptoms after infection may raise the question of acute-onset neuropsychiatric syndrome, which Ethan's gradual history does not suggest. Medications, such as stimulants, can worsen tics; he takes none.

Choosing Treatment

The AAN practice guideline on treatment of tics recommends that clinicians offer Comprehensive Behavioral Intervention for Tics as an initial treatment option for people with Tourette syndrome or chronic tic disorder when tics cause impairment, and considers medication for those whose tics remain impairing (Pringsheim et al., 2019). Piacentini et al. (2010) randomly assigned 126 children with Tourette or chronic tic disorder to CBIT or supportive therapy and education; CBIT produced a greater reduction on the Yale Global Tic Severity Scale, from 24.7 to 17.1 compared with 24.6 to 21.1, and more children were rated much or very much improved.

The Plan

I refer Ethan for CBIT, which teaches awareness of the premonitory urge and a competing response, a movement incompatible with the tic, along with changes to situations that worsen tics. Education for Ethan, his parents and his school is part of treatment: explaining that tics are involuntary, that drawing attention to them often makes them worse and that teasing must be addressed.

Why Not Medication First

Medications such as alpha-2 agonists or antipsychotics can reduce tics but carry side effects, including sedation, weight gain and, with antipsychotics, metabolic and movement effects. The guideline places behavioral therapy as an initial option because it is effective without these risks (Pringsheim et al., 2019). Medication remains an option if tics stay impairing despite therapy.

What CBIT Involves

CBIT typically involves about eight sessions over 10 weeks. Ethan will learn to notice the urge before each tic and perform a competing response, such as gentle nasal breathing instead of sniffing, for about a minute until the urge passes. His parents learn to praise his efforts without drawing attention to tics. Functional assessment identifies situations, such as video games or tiredness, that make tics worse.

The Mild Obsessive-Compulsive Features

His need to touch things an even number of times is mild and not currently impairing, but OCD symptoms often emerge or worsen in children with Tourette syndrome. I will monitor them and, if they grow, add assessment with a pediatric OCD scale and consider exposure and response prevention.

Emotional Impact

Children with tics may become anxious or withdrawn because of teasing. I ask Ethan how he feels at school; he admits he avoids reading aloud. Addressing peer reactions and building his confidence belong in the plan from the first visit.

Family Stress

Parents often feel guilty or anxious about tics and may ask the child to stop. I explain that asking a child to suppress tics can increase tension and rebound tics, and that praise for effort in therapy works better.

Monitoring

I will repeat the Yale Global Tic Severity Scale after CBIT to measure change, alongside Ethan's own rating of how much the tics bother him (Leckman et al., 1989).

Sleep and Stress

Tics worsen with fatigue and stress. I encourage regular sleep and a predictable routine, and ask the family to notice patterns that can be discussed in therapy.

Sports and Activities

Ethan plays soccer, which he enjoys and during which his tics lessen. Keeping activities he loves supports his confidence.

Explaining Tourette Syndrome to Ethan

I tell Ethan that tics are something his brain does, not something he chooses, and that many successful people have tics. He asks if he will have them forever; I explain that many children's tics get better as they get older.

Documentation

The note records tic types, onset, the scale scores and the screening results for comorbid conditions as a baseline for measuring the effect of therapy.

School

With permission, I write to his teacher explaining Tourette syndrome, requesting that tics be ignored in class, that Ethan be allowed breaks if needed and that teasing be addressed. A classroom presentation, with Ethan's agreement, can reduce stigma.

Prognosis

Tics often peak around ages 10 to 12 and lessen in adolescence for many children. I share this with the family as reassurance while emphasizing that treatment can help now.

Conclusion

Ethan's multiple motor and vocal tics over 18 months, with a premonitory urge and family history, meet criteria for Tourette syndrome, with moderate severity on the Yale Global Tic Severity Scale and mild obsessive-compulsive features. Following the AAN guideline and trial evidence, behavioral therapy is the first treatment, supported by education for the family and school and monitoring for co-occurring conditions.

References

Leckman, J. F., Riddle, M. A., Hardin, M. T., Ort, S. I., Swartz, K. L., Stevenson, J., & Cohen, D. J. (1989). The Yale Global Tic Severity Scale: Initial testing of a clinician-rated scale of tic severity. Journal of the American Academy of Child & Adolescent Psychiatry, 28(4), 566-573. https://doi.org/10.1097/00004583-198907000-00015

Piacentini, J., Woods, D. W., Scahill, L., Wilhelm, S., Peterson, A. L., Chang, S., Ginsburg, G. S., Deckersbach, T., Dziura, J., Levi-Pearl, S., & Walkup, J. T. (2010). Behavior therapy for children with Tourette disorder: A randomized controlled trial. JAMA, 303(19), 1929-1937. https://doi.org/10.1001/jama.2010.607

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906. https://doi.org/10.1212/WNL.0000000000007466