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Neurosci Lett 1: Am J Med Genet A 1: Mol Psychiatry 9 3: Acta Neurol Scand 4: J Psychiatry Neurosci 26 5: United Kingdom cohort study. Br J Psychiatry Eur Arch Psychiatry Neurol Sci 4: Psychopharmacology Berl 1: Ann Pharmacother 38 5: Dev Med Child Neurol 42 7: Am J Psyhiatry 5: Mol Psychiatry 3 1: Prog Neuropsychopharmacol Biol Psychiatry 28 2: J Psychosom Res 55 1: Pediatr Ann 17 6: Am J Hum Genet 59 3: Neural Plast 10 Am J Hum Genet 61 1: Rev Bras Psiquiatr 21 1: Arch Gen Med 8: Differential diagnosis and etiology of tics. Am J Med Genet 3: Bull Hist Med 69 2: Biol Psychiatry 51 1: Arch Psychiatry 43 Biol Psychiatry 34 7: Arch Neurol 46 1: Am J Psychiatry 9: J Clin Psychiatry 63 Dev Med Child Neurol 40 5: The neurobiological bases of obsessive compulsive disorder and Tourette syndrome.

J Pediatr Rio J 80 2 Suppl: Am J Hum Genet 67 4: J Neurol Sci Br J Psychiatry 2: J Neurol 7: Am J Hum Genet 75 4: Update on the genetics of Tourette syndrome. Am J Hum Genet 48 1: Am J Hum Genet 68 4: Wiley, New York, pp. Arch Gen Psychiatry 55 4: Clin Neurophysiol 2: Compr Psychiatry 36 2: Gilles de la Tourette syndrome — an update. J Child Psychol Psychiatry 35 4: Curr Opin Neurol 11 4: Williams and Wilkins, Maryland, pp. Am J Psychiatry 5: Rio de Janeiro, Am J Psychiatry 8: Rev Bras Psiquiatr 22 4: Ann Med Psychol Arch Gen Psychiatry 46 8: J Clin Psychiatry 62 9: Am J Med Genet Neurol Clin 15 2: Ann Neurol 12 4: J Neurol Neurosurg Psychiatry 52 7: Int Clin Psychopharmacol 15 1: J Child Adolesc Psychopharmacol 14 2: Am J Psychiatry 1: Am J Psychiatry 2: Effects of alpha methyl para tyrosine and tetrabenazine.

Arch Gen Psychiatry 31 6: J Neurol Neurosurg Psychiatry 67 6: An open pilot dose titration study with risperidone. Mov Disord 9 6: Behav Res Ther 42 5: Am J Psychiatry 6: Com o intuito de zelar pela fidedignidade dos dados coletados, as filmagens foram analisadas pelo pesquisador e por um outro observador.

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Nos jogos com bola gol a gol, basquete , Breno apresentou poucos tiques. Single case experimental designs. Strategies for studying behavior change. A tic is usually defined as a brief, repetitive, purposeless, nonrhythmic, involuntary movement or sound. Many simple motor tics are associated with the face, head, and neck region, such as eye blinking, head jerking, shoulder shrugging, mouth grimacing, etc. Simple vocal tics include throat-clearing sounds, grunting, sniffing, and coughing.

In contrast to simple tics, a complex tic involves a coordinated movement produced by a number of muscle groups complex motor tic or a linguistically meaningful utterance or phrase complex vocal tic. A chart of common tics pdf is presented in a separate table. At the present time, I think the safest approach is to view them as involuntary in children under the age of , and unvoluntary but possibly modifiable in those who are older.

The fact that they may be modifiable, however, does not mean that we can assume that an older child, teen, or adult would be able to modify them on their own without training or support. Within each type of tic condition, there is also a range of severity from mild and infrequent to severe and frequent. A significant minority of all children will experience one, or even a few, tics at some point in their development.

The transient tic condition observed in children is generally benign and usually does not require treatment. A chronic motor tic condition is one in which the individual has one or several motor tics on and off for more than a year. A chronic vocal tic condition is one in which the individual has one or a number of vocal tics on and off for more than a year. Years ago, it was common for physicians to put patients through a lot of neurological testing such as EEGs before making the diagnosis of TS. Today, many physicians do not order any tests unless there is some indication that other conditions can only be ruled out that way.

Do not be surprised, therefore, if the diagnosis is made after the physician takes a detailed history and performs a neurological examination in the office. A neurological examination involves checking the cranial nerves and asking the patient to perform certain tasks or activities — no sophisticated tests or instruments are required for that. If the tics are mild and infrequent, they may not warrant a separate diagnosis, but if the tics are problematic for the child, then they may warrant diagnosis and treatment. There is still some controversy about its rate in the general population.

The estimates you may read in the literature depend, in part, on how old the subjects were in the study studies of adults tend to significantly underestimate rates in children , and whether the subjects were drawn from clinical settings or from the general community, to name but two factors. That said, a study by Kurlan, McDermott, et al. These rates are somewhat higher than what was reported in UK schools. Because symptoms of TS tend to diminish with maturation, the rates of TS are lower in older individuals.

Although there has been considerable variability in estimates of rates in children in mainstream schools, all recent studies have reported higher rates in special education settings than in mainstream settings. The disproportionate representation of children with TS in special education does not prove that it is the tics or TS that are leading to school problems, however, and parents of children with tics should not fear that the tics, by themselves, will lead to a placement in special education. At the present time, and based on limited available research, it may well be the case that children with uncomplicated TS are not generally in need of special education as much as accommodations although those who have TS in the presence of other conditions such as Attention Deficit Hyperactivity Disorder may be represent a population with increased need for special education.

Like many other conditions, TS is much more common in males than in females. Many individuals report a sensory basis for their tics — they feel the need to tic building up as a kind of tension in a particular anatomical location, and they feel that they consciously choose to release it. Prado and her colleagues , review the literature on these experiences and note how they are reported in both TS and Obsessive-Compulsive Disorder patients, but moreso in TS.

These urges or internal. Can Tics be Suppressed? Thus, if we were to ask someone who felt that the tics were consciously released to not tic, we might observe that they could suppress a tic for a while, but eventually, they would release it. What happens if the individual tries to suppress the tics? Some individuals have no control at all over their tics, while others have varying degrees of control.


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Most adults report that their ability to modify or suppress their tics improved as they matured, and recent research supports the notion that as the child matures, their awareness of their tics and their ability to suppress them increase. With young children, it is important to remember that the child may not be aware of their tics, and even if they are aware, they may have no ability to suppress them. Parents frequently report that children or adolescents who try to suppress their tics in school all day with varying degrees of success will come home from school, walk in the door, and explode in tics — often accompanied by a lot of emotional behaviors.

For years, many of us considered these explosions of tics to represent an actual worsening of tics due to inhibition or suppression of tics during the school day. Recent research, however, casts some doubt on that interpretation. And just talking about their tics may induce a temporary worsening of their tics Woods, Watson, et al. Over a third of the children and adolescents in the sample reported experiencing PSP, and almost two-thirds.

Changes in reports were noted at two ages developmentally. At age 10, there seemed to be an increased ability to suppress tics, and at age 14, there was more reporting of PSP. It is important to note that awareness of premonitory sensory urges did not precede ability to suppress tics, but rather, ability to suppress tics actually preceded awareness of or experience of premonitory sensory urges.

If tics are actively suppressed, what happens to any preceding urges? Do they diminish over time or do they intensify and then diminish, or what? Their data provide some support for the notion that people tic to decrease or alleviate the unpleasant sensation that is building up. But what if we allow the period of tic suppression to go even longer?

Would the urge continue to build or would it eventually extinguish? Exposure-Response Prevention for tics is the same approach used in treating Obsessive-Compulsive Disorder. What factors predict ability to suppress tics or severity of sensory urges during training?

Data provided by Woods, Himle, et al. In the majority of cases, the first tics are usually simple motor tics of the head, face, neck, and shoulder region or simple phonic tics. For example, a child who suddenly starts sniffing may be thought to have a cold or allergies, but the pediatrician may find no evidence of a cold and no clear allergy symptoms such as rhinitis. Similarly, a child who suddenly starts blinking their. The tic increases in frequency and severity for a few weeks to a month or so, then starts to subside and eventually disappears.

Following the disappearance of the first tic or tics , a few months may go by and then the tic may re-emerge or a new tic may appear. The tic or tics will increase in frequency and severity over weeks and then subside and disappear. Indeed, this variability is the hallmark of TS, and is frequently a source of confusion for parents and educators. In almost all cases, TS emerges before age 18, but there are exceptions. In some children, TS may emerge more forcefully or explosively.

A child with no recognized history of tics may suddenly erupt in a number of tics within a very short period, or the child may present with complex tics instead of simple tics.


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Another situation in which severe tics or symptoms may emerge is those cases that appear to be related to infections PANDAS. Because of the changing anatomical location of the tics, the long tic-free periods between bouts of tic worsening, and because tics are often misunderstood as being due to other things, it used to take years before someone was properly diagnosed.

In the last few years, however, we have seen evidence that children are being diagnosed sooner, but the delay depends on a number of factors, including awareness by doctors, presence of other disorders, and age of the child at time of onset of symptoms. For example, in Israel, the median delay to diagnosis was only 6 months, but it was longer in cases where vocal tics were the first presentation or where the child was older.

The cooccurrence of other disorders resulted in a shorter delay to diagnosis Shilon et al. In Denmark, the median delay to diagnosis was 2. In the first years after tics first emerge, many people report that the waxing periods tend to worsen from one waxing cycle to the next. The good news is that for many individuals, the tics will ease up significantly or go into remission in the teen years.

A report by Leckman et al.

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In another study on changes over time, Burd, Kerbeshian, et al. In their sample, improvement in males was more variable than improvement in females, but overall, males demonstrated more improvement than females. Patient reports of symptoms improvement are often subjective, and a study by Pappert, Goetz, et al. They found that motor tic severity significantly decreased by adulthood, as did objective measures of overall tic disability.

While the majority of individuals seen in clinics appear to have a significant remission or improvement in tics, there are people who do not show improvement with age or whose tics worsen in adulthood. As an example, Pappert et al. For their sample, they found that that 10 of the 31 adults in their study had worse objective global tic disability scores as adults. There was a reliable and moderately strong correlation between the severity of objective global tic impairment at childhood and the severity of objective global tic impairment in adulthood.

Taken together, the data suggest that: A number of adults have reported that either their TS re-emerged after decades of being tic-free or that they are beginning to suffer adverse physical effects after years of severe ticcing. Unfortunately, while most clinicians seem to be aware of this, no one seems to be doing any long-term research to address these compelling adult needs and only a handful of published articles even refer to the re-emergence of TS after decades of quiet. It is important, however, to keep this caveat in mind: The goal was to help people remember that not everything may be a tic of TS, and that the child may have other conditions that may be responsible for any impairment they are experiencing.

This is particularly evident when we examine school functioning. Unfortunately, and despite my best efforts to remind people not to attribute everything to TS when it may be due to something else, all too many people continue to describe people with TS as having a variety of problems that may not be due to TS at all, but rather to some other condition. Such imprecise writing does not further our understanding of TS. It is one thing to say that children with TS and Attention Deficit Hyperactivity Disorder may be more likely to have processing deficits, but it is quite another thing to say that children with TS are more likely to have processing deficits.

So, what other disorders tend to be associated with or frequently comorbid with TS? The answer depends on whom you ask and whether the research is based on a clinical. That said, the majority of clinical settings report that a significant percentage of individuals who have TS also have obsessivecompulsive behaviors and Attention Deficit Hyperactivity Disorder.

Mood disorders such as depression and Bipolar Disorder are also commonly reported. Other researchers have reported either some support or total disagreement with Dr. But are all of these conditions really associated with tics, or is it the case that some of them are just associated with each other? Additional research is clearly needed to help identify patterns. Problems with conduct disorder or self-injurious behavior may be more common in those children with TS who are in the lowest quartile of height and weight.

Some studies, such as that by Kwak et al. The presence of migraine headaches did not appear to be linked with any obsessive-compulsive factors. In one of the few studies that looked at the question of personality disorders, Robertson et al. They reported that the TS patients were significantly more likely to have a personality disorder, and that many of the patients had more than one personality disorder. Their data indicate that about half of the adult TS patients had Borderline Personality Disorder and were also significantly more likely to have other personality disorders: So where does that leave parents of newly diagnosed children?

From my perspective, parents of newly diagnosed children need to be aware that: Some coprolalia is immediately obvious as a tic: Other coprolalia may be more difficult to recognize as a symptom since it is often triggered by cues in the immediate environment. As an example, an individual who has coprolalia may just blurt out whatever is inappropriate or unacceptable in a particular situation. The media has created a public misperception of what most people with TS can do and what they are like. As a direct consequence, many people are embarrassed to admit that they or their child has TS. Will he be teased because of his tics?

Even children or adults with extremely mild tics may experience psychosocial consequences. Two surveys of parents of children with TS indicate that many children are teased because of their tics, and a subset are actually rejected because of their tics Hagin et al. Even young children may reject peers for their tics. Research by Stokes , Friedrich et al. To date, however, there has been little research that has addressed whether an adequate peer education program could eliminate any negative peer evaluations, although some preliminary data Marcks et al. In light of the data on peer teasing and rejection due to tics, it is not surprising that some studies of quality of life QOL measures would indicate a difference between youth with TS and those without.

More recently, however, Pringsheim et al. For the TS-only children, only the family activities domain was significantly affected. The most significant predictor of psychosocial impairment was ADHD symptom severity. For children with TS-only, psychosocial health was not different from that of the general population in the majority of measures. As one example, Elstner et al. More recently, Gorman et al. Preliminary analyses of their data suggest that ADHD contributed significantly to overall impairment, as did OCD, but even after these factors were accounted for, TS still predicted worse psychosocial functioning.

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That said, one factor that has been identified as possibly predicting more severe impairment, however, is fine motor deficits and visual-motor integration deficits. All available research and clinical experience suggest that it does, but the assessment of its impact has been somewhat muddied by the presence of comorbid conditions. Pappert, Goetz, et al.

Their findings are consistent with other published reports from tertiary clinics, but it is their follow-up data on these children as adults that is of special interest and concern here. Out of their sample of 31, then, while the majority were doing well and were well-integrated in their communities, over one quarter of the adults were disabled with problems that included alcohol abuse, unemployment or criminal activity.

That these measures did not correlate with tic severity measures but did correlate with early childhood dysfunction suggests that early. If your child only has tics without any other comorbid symptoms or conditions, they may do quite well in a regular classroom as long as appropriate accommodations are made for interference they may experience from their tics.

Also consider whether your child suffers from fine motor control impairment or impaired visual-motor integration, as those two functions have a significant impact on academic functioning. At the present time, it appears that there is likely to be a significant genetic factor, although prenatal, perinatal, autoimmune, and environmental factors may contribute to or modulate the severity of symptoms. Gender is also linked to expression of TS: Female offspring had lower probabilities of showing symptoms of these disorders, but there was still a fairly high probability.

In more recent research, however, McMahon, Carter, Fredine, and Pauls approached the problem somewhat differently by looking at the onset of TS in children whose parents have TS and comparing that to the onset of TS in children whose parents do not have TS. None of the 13 control children developed a tic disorder, supporting the hypothesis of a significant genetic or familial contribution to the onset of tics. The data described above provide support for familial transmission of TS as well as an association between tics, obsessions and compulsions, and ADHD.

When the rates in offspring were compared, the investigators found that the rates of TS in children with two affected parents were three times the rate observed for children with one affected parent. Based on available reports, there is currently no clearly identified relationship between the severity of tics experienced by a parent in their childhood and the severity of tics experienced by their child ren. A parent who has mild symptoms might have a child who has severe systems Kurlan et al.

Children who had a family history of tics or obsessivecompulsive behaviors on both sides of the family were not only more likely to have more severe obsessive-compulsive behaviors, but they were also more likely to exhibit self-injurious behaviors. While some factors do not necessarily cause TS, they may be correlated with symptom severity in children who do develop TS. Some of the environmental factors that may affect symptom severity are mentioned later in this primer in the section on stress.

Some studies do report differences when comparing the brains of those with TS to those who do not have TS. A growing body of research also points to the role of structures in the brain known as the basal ganglia. A recent study by Sowell et al. They found cortical thinning in the frontal and parietal lobes compared to non-TS control children. Of particular significance, the thinning was most prominent in the sensorimotor areas of the cortex that control the facial, orolingual and laryngeal musculature.

Because facial tics and vocal tics are part of TS, their findings are particularly helpful in explaining some of the. Other researchers further expand our understanding by their study of white matter changes in the brain Siebner et al. Other research has addressed the neurochemical transmitters that might be involved in TS. Studies on dopaminergic function in individuals with TS has produced some fascinating results.

Stressors might take the form of environmental or ambient weather factors such as temperature, illness factors such as infection, or might include potential psychosocial stressors such as hassles on the job or in school, demanding environments, breakup of romances or marriages, death in the family, or any major life event. With respect to environmental factors, children or adults with TS may find that their symptoms are worse during allergy seasons, and preliminary data suggest that a subset of individuals with TS may also experience tic worsening associated with increased heat or room temperature Scahill et al.

Environmental factors were also noted to be significantly correlated with tic severity in another report by Snider et al. Because correlations between physiological responses and ambient environmental factors may not be present for all individuals and because such correlations may also vary by region and direction of correlation in individuals exposed to the same environmental conditions Wenger, ; Packer, , more research is needed before we can truly understand the contribution of ambient environmental factors to variability in tic severity.

In the past few years, a few additional studies have shed new light on the question of the relationship between everyday types of stressors and tic severity. For example, Findley and her colleagues reported that children with TS and OCD reported greater psychosocial stress than did their control peers, and that the reported level of psychosocial stress correlated with self-reports of tic and obsessive-compulsive symptom severity. In their study, four children with TS were videotaped while they were watching a. The investigators found that tic severity was worst during periods associated with anticipation, resolution of emotional changes, and lower concentration, while tic severity was lowest during periods of anger and happiness, and intermediate in severity during periods of sadness and fear.

Tic severity did not correlate with autonomic changes in heart or respiratory rate. It is important to note that both anger and happiness were associated with decreased tic severity, suggesting that it is not necessarily the positive emotional valence happiness that is associated with tic reduction. Using a self-report method of stressors and tic severity over a week period, Hoekstra et al. In looking at the group data, there were no correlations between SLE and tic severity measures in the pediatric group, and a weak but statistically significant i.

Overall, and keeping in mind the limitations of their design including the lack of objective verification of tic severity , the expected relationship between SLE and tic severity was not confirmed. Because group data and group analyses can sometimes obscure significant effects within individuals, the investigators also looked at individual correlations.

To complicate the picture even more, however, the direction of the correlation varied across individuals: Only in a minority of tic disorder patients do fluctuations in symptom severity appear to be associated with possibly stressful small life events. Hopefully, their research will inspire more research on this important topic. The relationship between infections such as strep infections and tics and OCD has been studied by a number of researchers; that research is summarized in the PANDAS section of this site. Interestingly, a new study by Lin et al. If stress does make the symptoms worse for a particular child or adult, does relaxation make the symptoms better?

While relaxation may lead to less tics, some people tic more as they start to relax and let all the tics out. In both cases, you will be simulating tics while trying to function. Exercise 1 As you read the text in the box below, frequently jerk your head back hard and fast. Try to do the head jerk in bursts — like two or three rapid jerks. Wait a few seconds, and do another hard, fast head jerk, or another burst. Do it frequently throughout your effort to read the material.

If you have a physical condition that prevents you from jerking your head back hard, do the exercise the same way but instead of jerking your head back hard and fast, roll your eyes severely to one side. OK, begin reading while you tic: Sometimes I feel like you are impatient with me because it takes me longer to do things or because I get frustrated during homework time, but I really am trying as hard as I can. It seems that the harder I try not to make the sounds or movements, the more I make them. Then I see that frustration or disappointment in your face and feel even worse. If I could stop it, I would.

How did you do?

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Did you experience interference in trying to read? Did you get dizzy or nauseous at all? Did you feel frustrated? If you were your child and trying to read, might you get fatigued or irritable after a while? Would you give up? Remember that you were only asked to read a few sentences. Tics of the eyes, head, and neck are the most common tics.

Allow extra time for activities where tics might interfere. Give your child opportunities to get up and move around to release tics if they need to and if it helps. If your child is older, work collaboratively with them to help them to learn to manage tics that might be socially problematic such as spitting. Please adjust the volume on your computer speakers to a comfortable level. When you click on the link below, you will hear a public service announcement from a national organization.

The announcement was recorded in So how did you do with this one? Were you able to listen and to process what you were hearing while you were ticcing? Feel free to share this exercise with other parents if you think it will help increase their awareness. The diagnosis of TS does not mean that the child or adult necessarily needs medication. Keep in mind that although stress does not cause TS, it can make the symptoms worse, so making lifestyle, school, or job changes that reduce stress may be of some benefit.

Rushing to treatment — whether it is medication or therapy — before making other changes is generally not a recommended course. The medications you would use for tics are not necessarily what you would use for another condition and treating one condition might make symptoms of another condition worse. Perhaps one of the best common-sense statements I have read about treatment appeared in a review article by Srour et al. The first therapeutic approach in tic disorders is education and demystification of symptoms.

Persons in frequent contact with the child should be informed about tics, fluctuations and possible co-morbidities. Such requests create tension which often exacerbates symptoms. The goal is to improve the tolerance of symptoms, and avoid situations that will augment stress or embarrassment. Following a complete evaluation, the treatment of tics and comorbidities should be prioritized according to the impairment caused by each problem.

Physicians considering pharmacological treatments should be aware of the fluctuating nature of tics and the effect of comorbidities on outcome. Medications for Tics Bloch , Srour et al. In terms of effectiveness, neuroleptic medications that block dopamine have generally been the most effective tic medications. An open label study by McCracken et al. They reported significant benefit in tics as well as in associated symptoms, but the absence of adequate control groups precludes any firm conclusions.

A number of preliminary reports suggest that it may be effective, including in patients who did not obtain satisfactory benefit from other neuroleptic medications [cf, Davies et al. Seo, Sung, et al. Similarly, Budman et al. Their review indicated that tics improved and explosive outbursts improved in those who did not discontinue treatment.

They, too, concluded that aripiprazole warrants further investigation as a treatment for TS. Although several studies and reviews have suggested that tetrabenazine may be of benefit in treating TS [cf, Ondo et al. Clonidine is actually a blood pressure medication, and does not pose the same risks as the neuroleptic medications. It also may have some beneficial effects on the symptoms of Attention Deficit Hyperactivity Disorder, which is frequently comorbid with TS.

Du, Li et al. Like all medications, clonidine does have some side effects that can be problematic. The most problematic side effects reported have been dry mouth and drowsiness or somnolence. Another disadvantage of clonidine is that it may take two to three months before an effect is detected, whereas neuroleptics often provide symptom relief within days of starting treatment. Its most common side effects are sedation and unsteadiness.

Adverse Effects of Medications Although the neuroleptics may be more potent in treating tics than clonidine, they have a more severe side effect profile. TD is a generally but not always irreversible movement disorder that may develop in some small percentage of patients who are on neuroleptics, while NMS is a rare but lifethreatening reaction characterized by high fever, rigidity, mental changes, and instability of the autonomic system.

NMS is usually treatable and reversible. The actual number of cases in which TD has developed in patients with TS is extremely small perhaps because of the low doses used when treating tics , but fear of developing TD has led many parents and patients to avoid those medications.

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Concerns have also been raised about cardiac changes in the QT interval with pimozide and ziprasidone, and many physicians will recommend pre-medication monitoring and periodic monitoring throughout treatment. The newer generation of neuroleptic medications have been linked to both weight gain and metabolic syndrome. The latter can lead to insulin resistance, high blood pressure hypertension , and high levels of triglycerides. Individuals with metabolic syndrome are at a two to three-fold increased risk of cardiovascular mortality and a two-fold increased risk of all-cause mortality Lakka et al, In , the US FDA asked the manufacturers of all atypical neuroleptics to revise their warning labels.

Warnings now include the increased risk of diabetes mellitus and hyperglycemia. For a review of the literature on the use of atypical neuroleptics in children and teens with a description of the types of adverse metabolic effects, see the article by Dr. Constadina Panagiotopoulos and her colleagues, available in free full-text online. The take-home message for parents and family members: In terms of day-to-day adverse effects, sleepiness, depressed mood, and weight gain are the most frequent concerns with the neuroleptics.

As with most medications, potential interaction between neuroleptics and other medications requires careful patient education. A study by Howson et al. Unlike central nervous system medications that affect the entire system, botulinum toxin acts locally think of getting an injection of local anesthetic for dental work as an analogy for a locally acting medication.

For example, Marras et al. A more recent study by Drs.

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Rath, Tavy, and their colleagues investigated the efficacy of botulinum toxin injections for simple motor tics in a sample of 15 patients who underwent repeat injections every three months. They reported short-term and long-term benefit of the injections, with three of the patients experiencing complete remission of the treated tics over a year follow-up period. In light of the efficacy data and reduced risk of adverse effects of the kinds associated with neuroleptic medications, this type of treatment might be considered sooner in the treatment protocols for individuals with chronic motor tics or powerful motor tics that are causing pain or injury to the individual.

Unfortunately, there do not seem to have been any controlled studies on this issue since that time the data do not really support its use. As applied to tics, habit reversal generally. Different investigators and clinicians may use slightly different variations in their protocols, but the competing response is a core feature of the technique.

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