NUR 7641 Module 3 Tourette Disorder Case: YGTSS Scoring, CBIT and When to Medicate Example

A Tic Score of 26 and a Boy Who Stopped Raising His Hand: Behavioral Therapy Before Medication in Tourette Disorder

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7641: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Child and Adolescent Populations, Part B

Mentor Name

Month Day, Year

A Tic Score of 26 and a Boy Who Stopped Raising His Hand: Behavioral Therapy Before Medication in Tourette Disorder

Two Years of Tics

Daniel is an invented patient, 12 years old and in seventh grade in Paterson. At age 10 he began blinking hard several times a minute, then added a sharp sideways jerk of his head and, about a year ago, a repeated throat clearing that his teachers took for a cold. The tics come and go in bouts, are worse when he is tired or excited and almost disappear when he plays the drums. He can hold them back for a few minutes in class, but they burst out afterward, and he describes a building itch in his neck before each jerk that the tic relieves.

Classmates have begun to copy the head jerk and call him names, and he no longer raises his hand. His grades are steady. His mother noticed he also needs to touch door frames an even number of times, and he takes a long time to start homework. There is no history of strep infections before the tics began, and his uncle had tics as a child that faded in his twenties.

Making the Diagnosis

Tourette disorder requires several motor tics and at least one vocal tic, present for more than a year and starting before age 18, not caused by a substance or another medical condition. Daniel has two motor tics and one vocal tic over two years, so he meets the criteria. His neurological examination is otherwise normal, and there are no features of a seizure or a movement disorder that would call for imaging or an electroencephalogram.

The premonitory urge, the relief after the tic and his ability to hold tics back briefly are typical of tics and help separate them from other movements. The guideline by Pringsheim et al. (2019) urges clinicians to assess for the conditions that commonly accompany tics, since these often cause more impairment than the tics themselves. His touching ritual raises the question of obsessive-compulsive symptoms, and his slow homework starts raise the question of ADHD. Teacher and parent ADHD ratings fall below the cutoff, and his touching takes under ten minutes a day without distress, so neither meets criteria now, but both are rechecked over time.

Measuring Severity

Leckman et al. (1989) developed the Yale Global Tic Severity Scale for clinicians to rate motor and vocal tics separately on number, frequency, intensity, complexity and interference, with a separate impairment rating. In testing with 105 people aged 5 to 51, the scale showed good construct, convergent and discriminant validity, and it remains the standard measure in tic research. Daniel's total tic score is 26, with 16 for motor and 10 for vocal tics, and his impairment rating is 20 because of the teasing and his withdrawal in class. A total tic score above 15 marks clinically meaningful tics in trials.

Options From the Guideline

Pringsheim et al. (2019) drew 46 recommendations from a systematic review, including counseling on the natural history of tics, education for teachers and classmates, screening for accompanying disorders and regular review of whether treatment is still needed. Treatment choices include watchful waiting, behavioral therapy and medication, and the choice should be shared among the young person, the family and the clinician. Many children's tics lessen in the late teens, as his uncle's did, and families should hear that.

For Daniel, watchful waiting with education alone was considered. It would suit a child whose tics cause little distress, but the teasing and his silence in class show real impairment. Medicines such as the alpha-2 agonists or antipsychotics reduce tics but carry side effects such as sleepiness, weight gain and metabolic changes. His family preferred to begin with therapy.

The Behavioral Trial

Piacentini et al. (2010) randomly assigned 126 children aged 9 to 17 with Tourette or chronic tic disorder to eight sessions of comprehensive behavioral intervention for tics or to supportive therapy with education. Total tic scores fell from about 25 to 17 with the behavioral intervention, compared with 25 to 21 in the control group, and 53 percent were rated much or very much better on the global scale, against 19 percent, so about one child in three treated responded who would not have otherwise. Tic worsening was rare, and most responders kept their gains six months later.

Daniel's Plan

Daniel starts eight weekly sessions of the behavioral intervention with a trained therapist. Habit reversal is its core. First he learns to notice the urge in his neck before each jerk; then he practices a competing response, gently tensing his neck muscles and looking straight ahead for a minute, which makes the jerk impossible. A similar response, slow breathing through the nose, is practiced for the throat clearing. His mother learns to praise his practice without commenting on the tics themselves.

The intervention also looks at what makes tics worse. Tics increase when he is rushed in the morning and when teachers point them out, so his mornings are given ten extra minutes and, with consent, his teachers receive a short written explanation of Tourette disorder and are asked not to comment on tics in class. His science teacher offers to give a brief talk to the class with Daniel's permission, which he accepts.

Follow-Up and Next Steps

The YGTSS is repeated after the eighth session and at three months. If tics remain impairing despite practice, an alpha-2 agonist would be the first medicine considered, especially if ADHD symptoms emerge, with blood pressure and pulse checked at each visit. His touching ritual and attention are rechecked at each review, and the family is told that tics often wax and wane, so a bad week does not mean treatment has failed.

Conclusion

Daniel meets criteria for Tourette disorder, with a total tic score of 26 and meaningful impairment from teasing at school. The neurology guideline calls for education, screening for accompanying conditions and a shared choice among watchful waiting, behavioral therapy and medicine. The behavioral intervention trial showed that eight sessions of habit reversal and related steps helped about half of children, so it is his first treatment, supported by his school, with medicine held in reserve.

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 and 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., Muller-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