ADD vs. ADHD
Wednesday, July 16, 2008
What is the Difference Between ADD and ADHD?
The difference between ADD and ADHD, in short, is a simple “nothing.” But since I’m sure you want a more of a detailed explanation, I will elaborate.
Through the years ADHD (Attention Deficit/Hyperactive Disorder) has had many names. ADD (Attention Deficit Disorder) is one of those many names. ADD has been used so recently and so frequently that many people still use it instead of ADHD. This has naturally created confusion among adults with ADHD and parents of children who have ADHD. It raises the question “Which one do I have?”
Imagine there is a new disease in San Francisco. The doctors study it and call it “Disease A.” Later that week, in Denver, doctors discover that same disease and not knowing that disease already exists, call it “Disease B.” Everywhere this disease shows up it is called by a different name. No one has made the connection that Disease A is the same thing as Disease B and C and D and etc... One day all the doctors get together at a conference and decide that all these alphabet diseases are the same thing. They call it by one name since twenty names for the same disease is confusing.
Now, try to relate the fictional story to ADHD, previously known as ADD, brain damaged syndrome, minimal brain dysfunction (MBD), hyperkinetic impulsive disorder, and so on. Since all of these have no major differences and are almost exactly alike, they are given one name. While the diversity is not as substantial, there are different types of ADHD just as there are different types of cancer. Could you imagine if lung cancer was called something totally different than colon cancer? It would get very confusing.
Some professionals still use the term “ADD” but it is the same as if they used “ADHD.” To sum it up, ADD technically is ADHD and vice versa.
There are two main types of ADHD: Inattentive and Hyperactive. Both are considered ADHD. If someone is diagnosed with ADD it’s the same as “ADHD: Predominately inattentive.” Predominately inattentive means that the hyper-active elements of ADHD are not as relevant but not totally excluded with that individual.
The Inattention Symptoms of ADHD
A person with ADHD might do any or all of these things that display a lack of attention chronically for more than six consecutive months:
- Loses things
- Seems not to listen
- Has difficulty keeping attention on something
- Avoids tasks requiring focus for any sustained amount of time
- Gets easily distracted
- Is very un-organized
- Has problems following instructions
- Is forgetful in the short-term
- Makes careless mistakes
- The Hyper-Active Symptoms of ADHD
A person with ADHD might do any or all of these things that display Hyperactivity, chronically for more than six consecutive months:
- Interrupts without noticing
- Talks too much
- Can’t stay still or fidgets
- Has problems with doing activities quietly
- Difficulty waiting in line or taking turns
- Very impatient
- Runs around or climbs excessively
Posted byDoc Junhel at 3:42 PM 0 comments
Emotional or Behavioral Disorder
Emotional conditions such as schizophrenia, depression, substance addictions, bipolar disorder, panic or phobic anxieties, and sleep disorders may have their bases in a brain dysfunction. Structural, chemical, or metabolic abnormalities in the brain may give rise to symptoms of one or more of these problems. Usually, if an emotional disorder is caused primarily by a brain problem, neuropsychological (cognitive) symptoms (e.g., memory, language, and thinking problems) will be present. Neuropsychological examination is a key diagnostic procedure to differentiate brain-based emotional problems from other sources of emotional symptoms.
The key purpose of a neuropsychological screening examination is to make an initial differential diagnosis to clarify the direction of further diagnostic study and, ultimately, treatment.
The American Psychological Association provides information and links related to a variety of emotional and mental health problems.
The University of Kansas Behavioral and Emotional Disturbance Resources page can lead you to additional, targeted information.
Internet Mental Health provides more information on emotional disorders.
Emotional and behavioral disorders (EBD) is a broad category which is used commonly in educational settings, to group a range of more specific perceived difficulties of children and adolescents. Both general definitions as well as concrete diagnosis of EBD may be controversial as the observed behavior may depend on many factors.
Often EBD students may have other disabilities such as: PDD, autism, Rett syndrome, PDD-NOS, Asperger syndrome and ADHD.
Strategies for students classified with EBD
1. Routine: Provide a structured routine with visual time clock. Auditory sound cues may be helpful in addition to visual cues to help students manage their time efficiently. Post schedule and refer to schedule on regular basis. Routines may take 6-8 weeks to establish or even more for this population of students.
2. Changes in Routine: Convey any changes of routine to students as soon as available. The sooner students are aware of changes the more time students have to adjust to the new routine.
3. Classroom Jobs Chart/Classroom Order Chart: Classroom jobs offer an opportunity for student to show responsibility. In order to ensure success, make sure students have an opportunity to experience every job. One suggestion is having a chart with each students name and according job. Every week rotate the jobs. The list can double as the order in which students line up or choose preferred activities. Students with EBD classification tend to be competitive and need specific procedures informing the order students line up and choose activities.
4. Logical Consequences: Students must fix what they break. If a student pushes over a desk, he or she must pick it up. If a student runs in the hall, she must practice walking the correct way. If the student talks during the lesson, student must make up the work on his time. Be consistent with consequences so students know what is expected of them.
5. Target Behaviors: After taking data on students observable behavior, determine which behavior or behaviors to direct attention. Work with student to develop a plan to replace undesirable behavior with a more suitable behavior. If student throws desks and pencils when angry, have student work on communicating anger to an adult or trusted peer and how to be assertive without being aggressive.
6. Small Flexible Grouping: Students with EBD may have difficulty establishing relationships with peers. Abusive language and other behaviors may interfere with learning. Smaller groups decrease distractions and student-to-teacher ratio. Differentiation of instruction is more manageable with smaller groups.
7. Audience: During a serious behavior episode, the most effective strategy may be to remove the audience. The audience typically is other peers but may be other adults. The audience can be removed by moving the student if he or she is willing. However, moving the audience may be necessary in some cases. Develop a procedure with your class which will function as an "everybody out" drill. Behaviors amplified with an audience may be reduced or complete stopped when an audience is removed.
8. Calm spot: Have a designated area of the classroom for students to calm down. This spot can be used pro actively to prevent behaviors. Alternatively, the spot may be used after a behavior occurs to give the student a chance to refocus.
9. Choices: Students may frustrate easily when doing work. Giving students an option of when to complete the work is a powerful tool. For example, a teacher may say, "You need to get this done today. Would you rather do it now or during your free time?"
What is an Emotional or Behavioral Disorder?
Although childhood is generally regarded as a
carefree time of life, many children and adoles-
cents experience emotional diffi culties growing
up. Identifying an emotional or behavioral dis-
order is diffi cult for many reasons. For instance,
it cannot be stated with certainty that something
"goes wrong" in the brain, causing a child to act
in a particular way. Contrary to early psychi-
atric theories, it is impossible to conclude that
a mother or father did something wrong early
in a child's life, causing an emotional or behav-
ioral disorder. Th e question of who or what is
responsible for a child's problems has given way
to an understanding that the combinations of
factors aff ecting development biological, en-
vironmental, psychological - are almost limit-
less.
Children's behaviors exist on a continuum, and
there is no specifi c line that separates troubling
behavior from a serious emotional problem.
Rather, a problem can range from mild to seri-
ous. A child is said to have a specifi c "diagnosis"
or "disorder" when his or her behaviors occur
frequently and are severe. A diagnosis repre-
sents a "best guess" based on a child's behaviors
that he or she has a specifi c mental health dis-
order and not just a problem that all children
might have from time to time. Research on the
cause of emotional disorders has shown that the
way the brain receives and processes informa-
tion is diff erent for children with some types of
disorders than for those who do not have those
problems. However, this is not true for all chil-
dren with emotional disorders.
Th ere have been many recent advances in un-
derstanding the emotional problems of chil-
dren and adolescents. As technologies are de-
veloped to study the central nervous system
and the relationships between brain chemistry
and behavior, the research is providing new
understanding of how and why some children
develop emotional disorders. Still interviews
with the child, parents or other family mem-
bers remain one of the most important sources
of information to help professionals arrive at a
diagnosis.
A diagnosis of a mental health disorder will be
based on one of several classifi cation systems
used in the United States. Th e most familiar
system is the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition Revised. Th e
DSM-IVR contains descriptions of specifi c be-
havioral characteristics that are used to deter-
mine whether a child or adult has an emotional
or mental disorder. Th e criteria that establishes
the presence of a mental health disorder are
subject to interpretation that may vary from
professional to professional. Cultural and sub-
jective criteria such as race, socioeconomic sta-
tus, or the behaviors of the child's parents at the
time of evaluation have an eff ect on professional
opinion, as does the training of the professional
and his or her years of experience.
A DSM-IVR diagnosis serves several purposes.
First, it may establish the presence of a specifi c
mental health problem which has an accepted
treatment standard, such as the use of medica-
tion in treating depression. Second, a formal di-
agnosis may be required for insurance or Med-
icaid reimbursement. A diagnosis for a child
may mean that insurance may cover the costs
of services the child needs but would not be eli-
gible for without the diagnosis.
Parents should bring up issues they believe may
infl uence their child's diagnosis during the eval-
uation. Th ese infl uences must be considered by
the evaluator in making a diagnosis. Generally,
determining whether a child has a biological-
ly based mental illness, a behavioral problem
or an emotional disorder is not as important
to a family as determining what interventions
are the most useful to help support their child.
What an evaluation should yield, regardless of
whether a child's problems result in a diagnosed
disorder or something less defi nitive, is a set of
disorder
disorder
recommendations for how to support him or
her in developing necessary skills.
Th e question about whether a child needs help
should not depend on whether he or she has a
diagnosis. A problem does not disappear sim-
ply because it is not severe enough to meet the
criteria for a diagnosis. Parents should insist on a list of specific
written recommendations for how to help their child as a result
of any evaluation.
The DSM IVR, for instance, lists eighteen separate characteris-
tics of behavior attributed to attention deficit hyperactivity dis-
order (ADHD). If a child shows six signs of inattention or six
signs of hyperactivity and impulsivity, he or she may be given a
clinical diagnosis of ADHD. This means that the mental health
professional working with the child believes that the child has
a medically-based problem and may recommend a specific
therapy, such as medication. But the characteristics by which
ADHD is diagnosed are also open to interpretation. What does
it mean to say that a child is “often distracted by extraneous
stimuli?” How often is often? What does distracted by mean?
And what happens to the child who shows only five signs of in-
attention and therefore does not have ADHD, but is still failing
in school and is unable to stay focused on his or her work?
Different professionals view emotional and behavioral dis-
orders in different ways. Their outlook—and their treatment
plan—is usually shaped by their training, their experience,
and their philosophy about the origins of a child’s problems.
Though the philosophical orientation or direction may not
seem important to parents who are frantically seeking a way to
locate help for their child, it is still recommended that parents
discuss such beliefs with professionals they contact. Since the
treatment program for a child will stem from the professional’s
philosophy, parents should be sure they agree with “where the
professional is coming from,” as well as with the methods used
by the professional to help their child. Otherwise, their coop-
eration in the treatment process may be compromised. When
seeking a treatment program for a child, parents may also want
to seek a second opinion if they disagree with the approach
suggested by the first mental health professional.
The following examples of emotional and behavioral disorders
are from the DSM-IVR diagnostic criteria. This list is not com-
prehensive, but is included to give parents examples of emo-
tional disorders affecting children and youth.
Adjustment Disorders describe emotional or behavioral
symptoms that children may exhibit when they are un- able,
for a time, to appropriately adapt to stressful events or changes
in their lives. The symptoms, which must occur within three
months of a stressful event or change, and last no more than six
months after the stressor ends, are: marked distress, in excess
of what would be expected from exposure to the event(s), or
an impairment in social or school functioning. There are many
kinds of behaviors associated with different types of adjustment
disorders, ranging from fear or anxiety to truancy, vandalism,
or fighting. Adjustment disorders are relatively common, rang-
ing from 5% to 20%.
Anxiety Disorders are a large family of disorders (school pho-
bia, posttraumatic stress disorder, avoidant disorder, obsessive-
compulsive disorder, panic disorder, panic attack, etc.) where
the main feature is exaggerated anxiety. Anxiety disorders may
be expressed as physical symptoms, (headaches or stomach
aches), as disorders in conduct (work refusal, etc.) or as in-
appropriate emotional responses, such as giggling or crying.
Anxiety occurs in all children as a temporary reaction to stress-
ful experiences at home or in school When anxiety is intense
and persistent, interfering with the child’s functioning, it may
become deemed as an Anxiety Disorder.
Obsessive-Compulsive Disorder (OCD) which occurs at a
rate of 2.5%, means a child has recurrent and persistent ob-
sessions or compulsions that are time consuming or cause
marked distress or significant impairment. Obsessions are
persistent thoughts, impulses, or images that are intrusive and
inappropriate (repeated doubts, requirements to have things
in a specific order, aggressive impulses, etc.). Compulsions are
repeated behaviors or mental acts (hand washing, checking,
praying, counting, repeating words silently, etc.) that have the
intent of reducing stress or anxiety. Many children with OCD
may know that their behaviors are extreme or unnecessary, but
are so driven to complete their routines that they are unable to
stop.
Post-Traumatic Stress Disorder (PTSD) can develop fol-
lowing exposure to an extremely traumatic event or series of
events in a child’s life, or witnessing or learning about a death
or injury to someone close to the child. The symptoms must
occur within one month after exposure to the stressful event.
Responses in children include intense fear, helplessness, dif-
ficulty falling asleep, nightmares, persistent re-experiencing
of the event, numbing of general responsiveness, or increased
arousal. Young children with PTSD may repeat their experi-
ence in daily play activities, or may lose recently acquired skills,
such as toilet training or expressive language skills.
Selective Mutism (formerly called Elective-Mutism) occurs
when a child or adolescent persistently fails to speak in specific
social situations such as at school or with playmates, where
speaking is expected. Selective mutism interferes with a child’s
educational achievement and social communication. Onset of
Selective Mutism usually occurs before the age of five, but may
not be evaluated until a child enters school for the first time.
The disorder is regarded as relatively rare, and usually lasts for
a period of a few months, although a few children have been
known not to speak in school during their entire school ca-
reer.
Attention Deficit/Hyperactivity Disorder is a condition, af-
fecting 3%-5% of children, where the child shows symptoms
of inattention that are not consistent with his or her develop-
mental level. The essential feature of Attention Deficit Hyper-
activity Disorder is “a persistent pattern of inattention and/or
hyperactivity-impulsivity that is more frequent and severe than
is typically observed in individuals at a comparable level of de-
velopment.” A few doctors have written articles on ADHD in
early childhood, and some suggest that signs of the disorder
can be detected in infancy. Most physicians prefer to wait un-
til a clear pattern of inattentive behaviors emerge that affect
school or home performance before attempting to diagnose
ADHD. Medications, such as Ritalin or Dexedrine, or a combi-
nation of these and other medicines have been very successful
in treating ADHD.
Oppositional Defiant Disorder. The central feature of oppo-
sitional defiant disorder (ODD), which occurs at rates of 2 to
16%, is “a recurrent pattern of negativistic, defiant, disobedient
and hostile behaviors towards authority figures, lasting for at
least six months …” The disruptive behaviors of a child or ado-
lescent with ODD are of a less severe nature than those with
Conduct Disorder, and typically do not include aggression to-
ward people or animals, destruction of property, or a pattern of
theft or deceit. Typical behaviors include arguing with adults,
defying or refusing to follow adult directions, deliberately an-
noying people, blaming others, or being spiteful or vindictive.
Conduct Disorder, which affects between 6% and 16% of boys
and 2% to 9% of girls, has as the essential feature “a repetitive
and persistent. pattern of behavior in which the basic rights
of others or major age-appropriate social norms or rules are
violated.” Children with Conduct Disorder often have a pat-
tern of staying out late de- spite parental objections, running
away from home, or being truant from school. Children with
Conduct Disorder may bully or threaten others or may be
physically cruel to animal and people. Conduct Disorder is of-
ten associated with an early onset of sexual behavior, drinking,
smoking, and reckless and risk-taking acts.
Anorexia Nervosa can be thought of as a “distorted body im-
age” disorder, since many adolescents who have Anorexia see
themselves as overweight and unattractive. In Anorexia Ner-
vosa, the individual refuses to maintain a minimally normal
body weight, is intensely afraid of gaining weight, and has no
realistic idea of the shape and size of his or her body. Signs
of anorexia nervosa include extremely low body weight, dry
skin, hair loss, depressive symptoms, constipation, low blood
pressure, and bizarre behaviors, such as hiding food or binge
eating.
Bulimia Nervosa is characterized by episodes of “binge and
purge” behaviors, where the person will eat enormous amounts
of food, then induce vomiting, abuse laxatives, fast, or follow
an austere diet to balance the effects of dramatic overeating.
Essential features are binge eating and compensatory methods
to prevent weight gain. Bulimia Nervosa symptoms include the
loss of menstruation, fatigue or muscle weakness, gastrointesti-
nal problems or intolerance of cold weather. Depressive symp-
toms may follow a binge and purge episode.
Bipolar Disorder (Manic Depressive Disorder)has symptoms
that include an alternating pattern of emotional highs and
emotional lows or depression. The essential feature of Bipolar
1 Disorder is “a clinical course that is characterized by the
occurrence of one or more Manic Episodes (a distinct period
during which there is an abnormally and persistently elevated,
expansive or irritable mood), or Mixed Episodes (a period of
time lasting at least one week in which the criteria are met
both for a Manic Episode and a Depressive Episode nearly
every day).” There are six different types of Bipolar 1 Disorder,
reflecting variations in manic and depressive symptoms.
Major Depressive Disorder occurs when a child has a series
of two or more major depressive episodes, with at least a two-
month interval between them. Depression may be manifested
in continuing irritability or inability to get along with others,
and not just in the depressed affect. In Dysthymic Disorder,
the depressed mood must be present for more days than not
over a period of at least two years. Dysthymic Disorder and
Major Depressive Disorder are differentiated based on severity,
chronicity, and persistence. Usually, Major Depressive Disorder
can be distinguished from the person’s usual functioning,
whereas Dysthymic Disorder is characterized by chronic, less
severe depressive symptoms that have been present for many
years.
Autistic Disorder is a Pervasive Developmental Disorder,
characterized by the presence of markedly abnormal or impaired
development in social interaction and communication, and a
markedly restricted level of activities or interests. Children with
Autism may fail to develop relationships with peers of the same
age, and may have no interest in establishing friendships. The
impairment in communication (both verbal and nonverbal) is
severe for some children with this disorder.
Schizophrenia is a serious emotional disorder characterized
by loss of contact with environment and personality changes.
Hallucinations and delusions, disorganized speech, or catatonic
behavior often exist as symptoms of this disorder, which is
frequently manifest in young adulthood. The symptoms may
also occur in younger children. There are a number of subtypes
of schizophrenia, including Paranoid Type, Disorganized Type,
Catatonic Type, Residual Type, and Undifferentiated Type. The
lifetime prevalence of Schizophrenia is estimated at between
0.5% and 1%.
Tourette’s Disorder occurs in approximately 4-5 individuals
per 10,000. The disorder includes both multiple motor tics and
one or more vocal tics, which occur many times per day, nearly
every day, or intermittently throughout a period of more than
one year. During this period, there is never a tic-free period of
more than 3 consecutive months. Chronic Motor or Vocal Tic
Disorder includes either motor ties or vocal tics, but not both
as in Tourette’s Disorder. Transient Tic Disorder includes either
single or multiple motor tics many times a day for at least four
weeks, but for no longer than 12 months. This can occur as
either a single episode or as recurrent episodes over time.
Seriously Emotionally Disturbed, or SED, is not a DSM-IVR
medical diagnosis, but a label that public schools may use
when children, due to their behaviors, are in need of special
education services. School professionals may or may not use
diagnostic classification systems as part of this determination.
The school’s responsibility is to provide services for students
with emotional or behavioral disorders or mental illnesses un-
der the special education category of SED (many states have
chosen to use a “different” label such as Emotional or Behav-
ioral Disorder (EBD), to describe this special education service
category), when their emotional or behavioral problems are so
severe that they cannot succeed without help.
Posted byDoc Junhel at 3:18 PM 0 comments
Tourette Syndrome
Tourette's was once considered a rare and bizarre syndrome, most often associated with the exclamation of obscene words or socially inappropriate and derogatory remarks (coprolalia). However, this symptom is present in only a small minority of people with Tourette's.[1] Tourette's is no longer considered a rare condition, but it may not always be correctly identified because most cases are classified as mild. Between 1 and 10 children per 1,000 have Tourette's;[2] as many as 10 per 1,000 people may have tic disorders,[3][4] with the more common tics of eye blinking, coughing, throat clearing, sniffing, and facial movements. People with Tourette's have normal life expectancy and intelligence. The severity of the tics decreases for most children as they pass through adolescence, and extreme Tourette's in adulthood is a rarity. Notable individuals with Tourette's are found in all walks of life.[5]
Genetic and environmental factors each play a role in the etiology of Tourette's, but the exact causes are unknown. In most cases, medication is unnecessary. There is no effective medication for every case of tics, but there are medications and therapies that can help when their use is warranted. Explanation and reassurance alone are often sufficient treatment;[6] education is an important part of any treatment plan.[7]
The eponym was bestowed by Jean-Martin Charcot (1825–93) on behalf of his resident, Georges Albert Édouard Brutus Gilles de la Tourette (1859–1904), a French physician and neurologist, who published an account of nine patients with Tourette's in 1885.
Characteristics
Tics are movements or sounds "that occur intermittently and unpredictably out of a background of normal motor activity",[13] having the appearance of "normal behaviors gone wrong."[14] The tics associated with Tourette's constantly change in number, frequency, severity and anatomical location. Waxing and waning—the ongoing increase and decrease in severity and frequency of tics—occurs differently in each individual. Tics also occur in "bouts of bouts", which vary for each person.[8]
Coprolalia (the spontaneous utterance of socially objectionable or taboo words or phrases) is the most publicized symptom of Tourette's, but it is not required for a diagnosis of Tourette's. According to the Tourette Syndrome Association, fewer than 15% of Tourette's patients exhibit coprolalia.[15] Echolalia (repeating the words of others) and palilalia (repeating one's own words) occur in a minority of cases,[8] while the most common initial motor and vocal tics are, respectively, eye blinking and throat clearing.[16]
| Video clips of tics |
|---|
| HBO documentary video clip |
| CBS News video clip |
| From the TSA, an adult with tics |
In contrast to the abnormal movements of other movement disorders (for example, choreas, dystonias, myoclonus, and dyskinesias), the tics of Tourette's are stereotypic, temporarily suppressible, nonrhythmic, and often preceded by a premonitory urge.[17] Immediately preceding tic onset, most individuals with Tourette's are aware of an urge[18][19] that is similar to the need to sneeze or scratch an itch. Individuals describe the need to tic as a buildup of tension, pressure, or energy[19][20] which they consciously choose to release, as if they "had to do it"[21] to relieve the sensation.[19] Examples of the premonitory urge are the feeling of having something in one's throat, or a localized discomfort in the shoulders, leading to the need to clear one's throat or shrug the shoulders. The actual tic may be felt as relieving this tension or sensation, similar to scratching an itch. Another example is blinking to relieve an uncomfortable sensation in the eye. These urges and sensations, preceding the expression of the movement or vocalization as a tic, are referred to as "premonitory sensory phenomena". Published descriptions of the tics of Tourette's identify sensory phenomena as the core symptom of the syndrome, even though they are not included in the diagnostic criteria.[20][22][23]
Tics are described as semi-voluntary or "unvoluntary",[13] because they are not strictly involuntary—they may be experienced as a voluntary response to the unwanted, premonitory urge. A unique aspect of tics, relative to other movement disorders, is that they are suppressible yet irresistible;[14] they are experienced as an irresistible urge that must eventually be expressed.[13] People with Tourette's are sometimes able to suppress their tics to some extent for limited periods of time, but doing so often results in an explosion of tics afterward.[6] People with Tourette's may seek a secluded spot to release their symptoms, or there may be a marked increase in tics, after a period of suppression at school or at work.[14]
Some people with Tourette's may not be aware of the premonitory urge. Children may be less aware of the premonitory urge associated with tics than are adults, but their awareness tends to increase with maturity.[13] They may have tics for several years before becoming aware of premonitory urges. Children may suppress tics while in the doctor's office, so they may need to be observed while they are not aware they are being watched.[24] The ability to suppress tics varies among individuals, and may be more developed in adults than children.
Although there is no such thing as a "typical" case of Tourette syndrome,[6] the condition follows a fairly reliable course in terms of the age of onset and the history of the severity of symptoms. Tics may appear up to the age of eighteen, but the most typical age of onset is from five to seven.[8] The ages of highest tic severity are eight to twelve (average ten), with tics steadily declining for most patients as they pass through adolescence.[25] The most common, first-presenting tics are eye blinking, facial movements, sniffing and throat clearing. Initial tics present most frequently in midline body regions where there are many muscles, usually the head, neck and facial region.[6] This can be contrasted with the stereotyped movements of other disorders (such as stims and stereotypies of the autism spectrum disorders), which typically have an earlier age of onset, are more symmetrical, rhythmical and bilateral, and involve the extremities (e.g., flapping the hands).[26] Tics that appear early in the course of the condition are frequently confused with other conditions, such as allergies, asthma, and vision problems: pediatricians, allergists and ophthalmologists are typically the first to see a child with tics.[8]
Among patients whose symptoms are severe enough to warrant referral to clinics, obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD) are often associated with Tourette's. Not all persons with Tourette's have ADHD or OCD or other comorbid conditions (co-occurring diagnoses other than Tourette's), although in clinical populations, a high percentage of patients presenting for care do have ADHD.[27] One author reports that a ten-year overview of patient records revealed about 40% of patients with Tourette's have "TS-only" or "pure TS", referring to Tourette syndrome in the absence of ADHD, OCD and other disorders.[28] Another author reports that 57% of 656 patients presenting with tic disorders had uncomplicated tics, while 43% had tics plus comorbid conditions.[14] "Full-blown Tourette's" is a term used to describe patients who have significant comorbid conditions in addition to tics.[14]
Causes
The exact cause of Tourette's is unknown, but it is well established that both genetic and environmental factors are involved.[29] Genetic studies have shown that the overwhelming majority of cases of Tourette's are inherited, although the exact mode of inheritance is not yet known,[30] and no gene has been identified.[6] In some cases, tics may not be inherited; these cases are identified as "sporadic" Tourette syndrome (also known as tourettism) because a genetic link is missing.[31]
A person with Tourette's has about a 50% chance of passing the gene(s) to one of his or her children, but Tourette's is a condition of variable expression and incomplete penetrance.[32] Thus, not everyone who inherits the genetic vulnerability will show symptoms; even close family members may show different severities of symptoms, or no symptoms at all. The gene(s) may express as Tourette's, as a milder tic disorder (transient or chronic tics), or as obsessive compulsive symptoms without tics. Only a minority of the children who inherit the gene(s) have symptoms severe enough to require medical attention.[15] Gender appears to have a role in the expression of the genetic vulnerability: males are more likely than females to express tics.[24]
Non-genetic, environmental, infectious, or psychosocial factors—while not causing Tourette's—can influence its severity.[6] Autoimmune processes may affect tic onset and exacerbation in some cases. In 1998, a team at the National Institute of Mental Health proposed a hypothesis that both obsessive-compulsive disorder (OCD) and tic disorders may arise in a subset of children as a result of a poststreptococcal autoimmune process.[33] Children who meet five diagnostic criteria are classified, according to the hypothesis, as having Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS).[34] This contentious hypothesis is the focus of clinical and laboratory research, but remains unproven.[35][36]
The exact mechanism affecting the inherited vulnerability to Tourette's has not been established, and the precise etiology is unknown. Tics are believed to result from dysfunction in cortical and subcortical regions, the thalamus, basal ganglia and frontal cortex.[29] Neuroanatomic models implicate failures in circuits connecting the brain's cortex and subcortex,[6] and imaging techniques implicate the basal ganglia and frontal cortex.[37]
Some forms of OCD may be genetically linked to Tourette's.[38] A subset of OCD is thought to be etiologically related to Tourette's and may be a different expression of the same factors that are important for the expression of tics.[39] The genetic relationship of ADHD to Tourette syndrome, however, has not been fully established.[28]
Diagnosis
According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), Tourette’s Disorder may be diagnosed when a person exhibits both multiple motor and one or more vocal tics (although these do not need to be concurrent) over the period of a year, with no more than three consecutive tic-free months. The previous DSM-IV included a requirement for "marked distress or significant impairment in social, occupational or other important areas of functioning", but this requirement was removed in the most recent update of the manual, in recognition that clinicians see patients who meet all the other criteria for Tourette's, but do not have distress or impairment.[40] The onset must have occurred before the age of 18, and cannot be attributed to the "direct physiological effects of a substance or a general medical condition".[9] Hence, other medical conditions that include tics or tic-like movements—such as autism or other causes of tourettism—must be ruled out before conferring a Tourette's diagnosis.
There are no specific medical or screening tests that can be used in diagnosing Tourette's;[8] it is frequently misdiagnosed or underdiagnosed, partly because of the wide expression of severity, ranging from mild (the majority of cases) or moderate, to severe (the rare, but more widely-recognized and publicized cases).[25] The diagnosis is made based on observation of the individual's symptoms and family history, and after ruling out secondary causes of tic disorders.[15] In patients with a typical onset and a family history of tics or obsessive–compulsive disorder, a basic physical and neurological examination may be sufficient.[11]
If a physician believes that there may be another condition present that could explain tics, tests may be ordered as necessary to rule out that condition. An example of this is when diagnostic confusion between tics and seizure activity exists, which would call for an EEG, or if there are symptoms that indicate an MRI to rule out brain abnormalities.[41] TSH levels can be measured to rule out hypothyroidism, which can be a cause of tics. Brain imaging studies are not usually warranted.[41] In teenagers and adults presenting with a sudden onset of tics and other behavioral symptoms, a urine drug screen for cocaine and stimulants might be necessary. If a family history of liver disease is present, serum copper and ceruloplasmin levels can rule out Wilson's disease.[11] However, most cases are diagnosed by merely observing a history of tics.[6][15]
Secondary causes of tics (not related to inherited Tourette syndrome) are commonly referred to as tourettism.[31] Dystonias, choreas, other genetic conditions, and secondary causes of tics should be ruled out in the differential diagnosis for Tourette syndrome.[11] Other conditions that may manifest tics or stereotyped movements include developmental disorders, autism spectrum disorders,[42] and stereotypic movement disorder;[43][44] Sydenham's chorea; idiopathic dystonia; and genetic conditions such as Huntington's disease, neuroacanthocytosis, Hallervorden-Spatz syndrome, Duchenne muscular dystrophy, Wilson's disease, and tuberous sclerosis. Other possibilities include chromosomal disorders such as Down syndrome, Klinefelter's syndrome, XYY syndrome and fragile X syndrome. Acquired causes of tics include drug-induced tics, head trauma, encephalitis, stroke, and carbon monoxide poisoning.[11][31] The symptoms of Lesch-Nyhan syndrome may also be confused with Tourette syndrome.[26] Most of these conditions are rarer than tic disorders, and a thorough history and examination may be enough to rule them out, without medical or screening tests.[6]
Screening
Although not all people with Tourette's have comorbid conditions, most Tourette's patients presenting for clinical care at specialty referral centers may exhibit symptoms of other conditions along with their motor and phonic tics.[28] Associated conditions include attention-deficit hyperactivity disorder (ADD or ADHD), obsessive–compulsive disorder (OCD), learning disabilities and sleep disorders.[3] Disruptive behaviors, impaired functioning, or cognitive impairment in patients with comorbid Tourette's and ADHD may be accounted for by the comorbid ADHD, highlighting the importance of identifying and treating comorbid conditions.[27][45] Disruption from tics is commonly overshadowed by comorbid conditions that present greater interference to the child.[6] Tic disorders in the absence of ADHD do not appear to be associated with disruptive behavior or functional impairment,[4] while impairment in school, family, or peer relations is greater in patients who have more comorbid conditions and often determines whether therapy is needed.[14]
Because comorbid conditions such as OCD and ADHD can be more impairing than tics, these conditions are included in an evaluation of patients presenting with tics. "It is critical to note that the comorbid conditions may determine functional status more strongly than the tic disorder," according to Samuel Zinner, MD.[6] The initial assessment of a patient referred for a tic disorder should include a thorough evaluation, including a family history of tics, ADHD, obsessive–compulsive symptoms, and other chronic medical, psychiatric and neurological conditions. Children and adolescents with TS who have learning difficulties are candidates for psychoeducational testing, particularly if the child also has ADHD.[41] Undiagnosed comorbid conditions may result in functional impairment, and it is necessary to identify and treat these conditions to improve functioning. Complications may include depression, sleep problems, social discomfort and self-injury.[11]
Management
The treatment of Tourette's focuses on identifying and helping the individual manage the most troubling or impairing symptoms.[6] Most cases of Tourette's are mild, and do not require pharmacological treatment;[12] instead, psychobehavioral therapy, education, and reassurance may be sufficient.[46] Treatments, where warranted, can be divided into those that target tics and comorbid conditions, which, when present, are often a larger source of impairment than the tics themselves.[41] Not all people with tics have comorbid conditions,[28] but when those conditions are present, they often take treatment priority.
There is no cure for Tourette's and no medication that works universally for all individuals without significant adverse effects. Knowledge, education and understanding are uppermost in management plans for tic disorders.[6] The management of the symptoms of Tourette's may include pharmacological, behavioral and psychological therapies. While pharmacological intervention is reserved for more severe symptoms, other treatments (such as supportive psychotherapy or cognitive behavioral therapy) may help to avoid or ameliorate depression and social isolation, and to improve family support. Educating a patient, family, and surrounding community (such as friends, school, and church) is a key treatment strategy, and may be all that is required in mild cases.[6][47]
Medication is available to help when symptoms interfere with functioning.[15] The classes of medication with the most proven efficacy in treating tics—typical and atypical neuroleptics including risperidone (trade name[A] Risperdal), ziprasidone (Geodon), haloperidol (Haldol), pimozide (Orap) and fluphenazine (Prolixin)—can have long-term and short-term adverse effects.[41] The antihypertensive agents clonidine (trade name Catapres) and guanfacine (Tenex) are also used to treat tics; studies show variable efficacy, but a lower side effect profile than the neuroleptics.[1] Stimulants and other medications may be useful in treating ADHD when it co-occurs with tic disorders. Drugs from several other classes of medications can be used when stimulant trials fail, including guanfacine (trade name Tenex), atomoxetine (Strattera) and tricyclics. Clomipramine (Anafranil), a tricyclic antidepressant, and SSRIs—a class of antidepressants including fluoxetine (Prozac), sertraline (Zoloft), and fluvoxamine (Luvox)—may be prescribed when a Tourette's patient also has symptoms of obsessive–compulsive disorder.[41]
Because children with tics often present to physicians when their tics are most severe, and because of the waxing and waning nature of tics, it is recommended that medication not be started immediately or changed often.[6] Frequently, the tics subside with explanation, reassurance, understanding of the condition and a supportive environment.[6] When medication is used, the goal is not to eliminate symptoms: it should be used at the lowest possible dose that manages symptoms without adverse effects, given that these may be more disturbing than the symptoms for which they were prescribed.[6]
Cognitive behavioral therapy (CBT) is a useful treatment when OCD is present,[48] and there is increasing evidence supporting the use of habit reversal in the treatment of tics.[49] Relaxation techniques, such as exercise, yoga or meditation, may be useful in relieving the stress that may aggravate tics, but the majority of behavioral interventions (such as relaxation training and biofeedback, with the exception of habit reversal) have not been systematically evaluated and are not empirically supported therapies for Tourette's.[50]
Prognosis
Tourette syndrome is a spectrum disorder—its severity ranges over a spectrum from mild to severe. The majority of cases are mild and require no treatment.[12] In these cases, the impact of symptoms on the individual may be mild, to the extent that casual observers might not know of their condition. The overall prognosis is positive, but a minority of children with Tourette syndrome have severe symptoms that persist into adulthood.[29] A study of 46 subjects at 19 years of age found that the symptoms of 80% had minimum to mild impact on their overall functioning, and that the other 20% experienced at least a moderate impact on their overall functioning.[8] The rare minority of severe cases can inhibit or prevent individuals from holding a job or having a fulfilling social life. In a follow-up study of thirty-one adults with Tourette's, all patients completed high school, 52% finished at least two years of college, and 71% were full-time employed or were pursuing higher education.[54]
Regardless of symptom severity, individuals with Tourette's can expect to live a normal life span. Although the symptoms may be lifelong and chronic for some, the condition is not degenerative or life-threatening. Intelligence is normal in those with Tourette's, although there may be learning disabilities.[15] There is no reliable means of predicting the outcome for a particular individual. The gene or genes associated with Tourette's have not been identified, and there is no potential "cure".[15]
Several studies have demonstrated that the condition in most children improves with maturity. Tics may be at their highest severity at the time that they are diagnosed, and often improve with understanding of the condition by individuals and their families and friends. The statistical age of highest tic severity is typically between eight and twelve, with most individuals experiencing steadily declining tic severity as they pass through adolescence. One study showed no correlation with tic severity and the onset of puberty, in contrast with the popular belief that tics increase at puberty. In many cases, a complete remission of tic symptoms occurs after adolescence.[25][55] However, a study using videotape to record tics in adults found that, although tics diminished in comparison with childhood, and all measures of tic severity improved by adulthood, 90% of adults still had tics. Half of the adults who considered themselves tic-free still displayed evidence of tics.[54]
It is not uncommon for the parents of affected children to be unaware that they, too, may have had tics as children. Because Tourette's tends to subside with maturity, and because milder cases of Tourette's are now more likely to be recognized, the first realization that a parent had tics as a child may not come until their offspring is diagnosed. It is not uncommon for several members of a family to be diagnosed together, as parents bringing children to a physician for an evaluation of tics become aware that they, too, had tics as a child.
Children with Tourette's may suffer socially if their tics are viewed as "bizarre". If a child has disabling tics, or tics that interfere with social or academic functioning, supportive psychotherapy or school accommodations can be helpful.[15] Because comorbid conditions (such as ADHD or OCD) can cause greater impact on overall functioning than tics, a thorough evaluation for comorbidity is called for when symptoms and impairment warrant.[11]
A supportive environment and family generally gives those with Tourette's the skills to manage the disorder.[57][58] People with Tourette's may learn to camouflage socially inappropriate tics or to channel the energy of their tics into a functional endeavor. Accomplished musicians, athletes, public speakers, and professionals from all walks of life are found among people with Tourette's. Outcomes in adulthood are associated more with the perceived significance of having severe tics as a child than with the actual severity of the tics. A person who was misunderstood, punished, or teased at home or at school will fare worse than children who enjoyed an understanding and supportive environment.[8]
A controlled study on a small group of individuals with Tourette's found that young people with the syndrome have greater cognitive control over movements than their age-matched controls, possibly because the need to suppress tics results in a more efficient control over inhibitory movements, a skill that confers an advantage when switching between tasks. Children with Tourette's (in the absence of comorbid ADHD) performed more accurately on a goal-oriented eye-movement task, requiring active inhibition of automatic eye movements, and they made fewer errors than their unaffected peers, suggesting compensatory changes in the brain resulting in greater cognitive control.[59] A subsequent study confirmed and extended the paradoxical result that individuals with Tourette's exhibit greater levels of cognitive control than age-matched healthy peers.[60] A study of eight children, age 8–17, found that children with Tourette syndrome were quicker at processing certain mental grammar skills than are children without the condition. The abnormalities that lead to tics may also lead to "other rapid behaviors, including the cognitive processing of rule-governed forms in language and other types of procedural knowledge".[61]
Epidemiology
Tourette syndrome is found among all social, racial and ethnic groups,[3][62] has been reported in all parts of the world,[63] and is three to four times more frequent among males than among females.[64] The tics of Tourette syndrome begin in childhood and tend to remit or subside with maturity; thus, a diagnosis may no longer be warranted for many adults, and prevalence is much higher among children than adults.[25] Children are five to twelve times more likely than adults to be identified as having tic disorders;[65] as many as 1 in 100 people experience tic disorders, including chronic tics and transient tics in childhood.[3]
Discrepancies across current and prior prevalence estimates come from several factors: ascertainment bias in earlier samples drawn from clinically referred cases, assessment methods that may fail to detect milder cases, and differences in diagnostic criteria and thresholds.[66] There were few broad-based community studies published before 2000 and until the 1980s, most epidemiological studies of Tourette syndrome were based on individuals referred to tertiary care or specialty clinics.[1][67] Children with milder symptoms are unlikely to be referred to specialty clinics, so these studies have an inherent bias towards more severe cases.[1][68] Studies of Tourette syndrome are vulnerable to error because tics vary in intensity and expression, are often intermittent, and are not always recognized by clinicians, patients, family members, friends or teachers;[6][69] approximately 20% of persons with Tourette syndrome do not recognize that they have tics.[6] Recent studies—recognizing that tics may often be undiagnosed and hard to detect—use direct classroom observation and multiple informants (parent, teacher, and trained observers), and therefore record more cases than older studies relying on referrals.[70][47] As the diagnostic threshold and assessment methodology have moved towards recognition of milder cases, the result is an increase in estimated prevalence.[66]
Tourette syndrome was once thought to be rare: in 1972, the US National Institutes of Health (NIH) believed there were fewer than 100 cases in the United States,[71] and a 1973 registry reported only 485 cases worldwide.[72] However, multiple studies published since 2000 have consistently demonstrated that the prevalence is much higher than previously thought.[73] The emerging consensus is that 1–10 children per 1,000 have Tourette's,[2] with several studies supporting a tighter range of 6–8 children per 1,000.[4] Using year 2000 census data, a prevalence range of 1–10 per 1,000 yields an estimate of 53,000–530,000 school-age children with Tourette's in the US[4] and a prevalence range of 6–10 per 1,000 means that 64,000–106,000 children aged 5–18 years may have Tourette's in the UK.[47] Most of these children are undiagnosed and have mild symptoms without distress or impairment.[63][70]
History and research directions
- Jean-Martin Charcot (1825–1893) was a French neurologist and professor who bestowed the eponym for Tourette syndrome on behalf of his resident, Georges Albert Édouard Brutus Gilles de la Tourette. Charcot is shown here during a lesson with a "hysterical" woman patient at the Salpêtrière hospital.
A French doctor, Jean Marc Gaspard Itard, reported the first case of Tourette syndrome in 1825,[74] describing Marquise de Dampierre, an important woman of nobility in her time.[12] Jean-Martin Charcot, an influential French physician, assigned his resident Georges Albert Édouard Brutus Gilles de la Tourette, a French physician and neurologist, to study patients at the Salpêtrière Hospital, with the goal of defining an illness distinct from hysteria and from chorea.[24]
In 1885, Gilles de la Tourette published an account of nine patients, Study of a Nervous Affliction, concluding that a new clinical category should be defined.[75] The eponym was later bestowed by Charcot after and on behalf of Gilles de la Tourette.[24][76]
Little progress was made over the next century in explaining or treating tics, and a psychogenic view prevailed well into the 20th century.[24] The possibility that movement disorders, including Tourette syndrome, might have an organic origin was raised when an encephalitis epidemic from 1918–1926 led to a subsequent epidemic of tic disorders.[77]
During the 1960s and 1970s, as the beneficial effects of haloperidol (Haldol) on tics became known, the psychoanalytic approach to Tourette syndrome was questioned.[78] The turning point came in 1965, when Arthur K. Shapiro—described as "the father of modern tic disorder research"[79]—treated a Tourette’s patient with haloperidol, and published a paper criticizing the psychoanalytic approach.[77]
Since the 1990s, a more neutral view of Tourette's has emerged, in which biological vulnerability and adverse environmental events are seen to interact.[6][24] In 2000, the American Psychiatric Association published the DSM-IV-TR, revising the text of DSM-IV to no longer require that symptoms of tic disorders cause distress or impair functioning.[80]
Findings since 1999 have advanced TS science in the areas of genetics, neuroimaging, neurophysiology, and neuropathology. Questions remain regarding how best to classify Tourette syndrome, and how closely Tourette's is related to other movement disorders or psychiatric disorders. Good epidemiologic data is still lacking, and available treatments are not risk free and not always well tolerated.[81] High-profile media coverage focuses on treatments that do not have established safety or efficacy, such as deep brain stimulation, and alternative therapies involving unstudied efficacy and side effects are pursued by many parents.[35]
Society and culture
Not everyone with Tourette's wants treatment or a "cure", especially if that means they may "lose" something else in the process.[82][83] Some people believe that there may be latent advantages associated with genetic vulnerability to the syndrome.[83] Cognitive control may be enhanced in young people with Tourette's because the need to suppress tics results in a more efficient control of inhibitions.[59] There is evidence to support the clinical lore that children with "TS-only" (Tourette's in the absence of comorbid conditions) are unusually gifted: neuropsychological studies have identified advantages in children with TS-only.[28][84] One study found that children with TS-only are faster than the average for their age group on timed motor coordination.[85]
Notable individuals with Tourette syndrome are found in all walks of life, including musicians, athletes and authors. The best-known example of a person who may have used obsessive–compulsive traits to advantage is Dr Samuel Johnson, the 18th-century English man of letters, who had Tourette syndrome as clearly evidenced by the writings of James Boswell.[86][87] Johnson wrote A Dictionary of the English Language in 1747, and was a prolific writer, poet, and critic.
Although it has been speculated that Mozart had Tourette's,[88][89] no Tourette's expert or organization has presented credible evidence to show that this was the case,[89] and there are problems with the available data.[90]
The entertainment industry often depicts those with Tourette syndrome as social misfits whose only tic is coprolalia, which has furthered stigmatization and the public's misunderstanding of those with Tourette's.[91] The coprolalic symptoms of Tourette's are also fodder for radio and television talk shows in the US[92] and in the British media.[93]
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