Ramdas had multiple tics of the shoulders and lower limbs and occasional vocal tics simulating clearing of the throat or a grunt. The more he tried to suppress them, the more stressed he became and almost like a rebound phenomenon, the build up of the tension would subsequently produce tics and grunts which were explosive in character. He walked the 1 km to school as before. He also ate and slept moderately well. How did these abnormal movements, over which he had no control, come about? He became irritable, lost his temper and exhibited a tendency towards defiance aimed particularly at parental control. He became socially withdrawn and stopped participating in extramural activities. He always had difficulty focusing in class, but now he was unable to pay attention even over short periods. Progressively, the knowledge gap in his studies widened and he lagged behind the class abysmally! Examinations became a nightmare! The tic disorder was unrelentingly eroding his self confidence and self esteem.
Ramdas’s parents, though in the middle range of middle class, with the mother a homemaker, decided in the early days that their only child must have the best education. From the 3rd grade, Ramdas was studying in one of the premier schools of the metropolis and would come rushing home, with bated breath, to share the day’s events with his mother over the hot tea and snack which she lovingly laid out for him. What went wrong? Had she slipped up somewhere along the way in her nurture of the child? Had she not propitiated the gods to thank them for the birth of this lovely child, who had grown even more charming and closer to her as the years rolled by?
The father was more down to earth and practical in his approach. The Neurology Consultant had told him that the patient had a chronic movement disorder with motor and vocal tics and attention deficit as a comorbid condition could affect his studies. The parents approached TriMed-Neurokrish when the school authorities directed them to avail of the holistic approach to treatment offered there.
Exploring the Condition
The goal set for the TriMed-Neurokrish team was in improving mood, self-esteem, academic performance and social functioning through oral medication, a range of integrated therapies and family counseling. Ramdas was started on Attentrol 10 mg – 1-0-0 (Amoxyteline Hcl) for ADHD and Sulpitac 50 mg – 0-0-1/2 (Amisulpride) – a neuroleptic, towards some control of vocal and motor tics and associated behaviors. Behaviour therapy was introduced with psychoeducation of the patient regarding the condition, (with parents participating in the dialogue with the team members). The first step was to build a foundation of self-esteem to help the child gain confidence to face his problems, and begin implementing skills. Our intensive therapy for Ramdas followed our protocol for children with Neurodevelopmental Disorders (NDD) and included a combination of two Ayurveda treatments (Shirodhara & Abhyangam), Play Yoga, Neurodevelopmental Therapy (NDT, a combination of physical and occupational therapies) and psychological therapy (behavioral and family). Sessions of NDT and BT often continue for months in regular periodicity, and include weekend opportunities to meet with peers (also in therapy), socialize, and develop skills of emotional expression.
A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization. Multiple motor tics involve several muscle groups, while a simple tic involves only one muscle group.
Gilles de la Tourette’s Syndrome or Tourette’s Syndrome is a neurodevelopmental condition characterised by multiple motor and vocal tics, which appear in childhood and are often accompanied by behavioural symptoms. For a diagnosis of Tourette’s syndrome
(DSM-V) the main criterion is that both multiple motor and 1 or more vocal tics have been present at some time during the illness, though not necessarily concurrently. It must stretch over a whole year, with tic-free period lasting less than three months at a stretch. The onset of the tics must be before the age of 18 years, and not due to other causes like substance abuse or secondary to other neurological conditions. A more recent behavioural intervention, (John Piacentini, 2010) which has been found effective in TS is Comprehensive Behavioral Intervention for Tics (CBIT), based on habit reversal training, for reducing tics and tic-related impairment in Tourette disorder. In CBIT, children with tics are trained to recognize the urge to tic, and to use a replacement or competing response instead of the tic.
- DSM-V – Diagnostic criteria for Tourette Disorder
- Andrea E. Cavana Tourette Syndrome – Clinical Review , BMJ, Aug 2013 ; 347 :1-6
- John Piacentini, Woods; D W., Scahil, L Behaviour Therapy for Children With Tourette Disorder-A Randomized Controlled Trial JAMA, May 19, 2010, Vol 303, No. 19
Ramdas has done well with us, and a follow up after 3 months saw an exceptionally changed young lad, with his head held high and much of his self-esteem regained. The tics had waned and subsequently stopped for over months. His behaviour had become closer to his original level of calmness with the therapies and yoga. He was no longer defiant. He pleaded with his parents to let him continue in his mainstream school and the school was willing to retain him, provided there was an extra effort to make up in his studies.
Ramdas’s parents who considered shifting him from a mainstream school to a school offering special education and Open School examination system reconsidered the decision and waited for the team specialist’s opinion before finalizing their decision. At TriMed-Neurokrish it was decided that with Ramdas who was showing marked improvement all round, with the stress, tics, and behavioural problems being put aside, with the attention deficit being minimized and with the motivation being high, could be given a fair trial of continuing for one term in his mainstream school, with a special educator to handle the areas of LD after school hours. Ramdas was elated and the parents were willing to follow the advice.
Regular follow up once a month or more often to reinforce the therapies, (which he continued at home under the supervision of his mother) ensures that he continues to show remarkable progress.