An Overview of Tourette Syndrome and Its Management

Additional Info

• Audio File:uab/ua190.mp3
• Doctors:Dure, Leon
• Featured Speaker:Leon Dure, MD
• CME Series:Clinical Skill
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4559
• Guest Bio:Leon Dure, MD is the Director of Child Neurology. 
  
  Learn more about Leon Dure, MD 
  
  Release Date: February 22, 2021
  Expiration Date: February 22, 2024
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no relevant financial relationships with ineligible companies to disclose.
  
  Speakers:
  Leon Dure, MD
  Director of Child Neurology
  
  Dr. Dure has no relevant financial relationships with ineligible companies to disclose.
  
  There is no commercial support for this activity.
• Transcription:Melanie Cole:  Welcome to UAB MedCast. I'm Melanie Cole, and I invite you to listen as we provide an overview of Tourette syndrome and its management. Joining me is Dr. Leon Dure. He's the director of Child Neurology at UAB Medicine.
  
  Dr. Dure, it's such a pleasure to have you join us today. So let's set the stage for other providers. What is Tourette syndrome? How prevalent is it? Tell us a little bit about it.
  
  Dr. Leon Dure: All right. Tourette syndrome is a condition that's defined as individuals who express a combination of both motor and vocal tics. There are chronic tic disorders that either only have motor tics or only have vocal tics, but I tend to think of them all as pretty much under the same umbrella. The duration of these tics has to be for a year in order to qualify for this diagnosis.
  
  Now, in terms of prevalence, it's actually fairly common. Although once considered to be a very rare and exotic disorder, it's estimated that anywhere in the low single percentages of the general population have features that would be diagnosable as Tourette syndrome.
  
  Melanie Cole: Well, then let's talk about that. Who's most commonly effected? Give us a little bit about average age, demographic breakdown. What do we know?
  
  Dr. Leon Dure: It's definitely present in all ethnic groups. And everywhere around the world, people have Tourette syndrome. It does tend to impact boys more than girls. And the usual age of onset is somewhere within about six to eight years of age. It's been estimated that in terms of tic frequency, how frequent their takes are occurring, that may peak at a later age of about 10-1/2 to 11 years of age, although there are adults and certainly teenagers who continue to manifest tics as they get older.
  
  Melanie Cole: Speak about the tics a little bit. Are they cookie cutter? Are they different for every patient? What are some of the characteristics of these symptoms and what is the wide range of them?
  
  Dr. Leon Dure: That's a really good point. The tics are in themselves normal movements. What makes them abnormal is the frequency and context. So anything can be a tic, meaning that simple blinking or mouth opening, et cetera, can be a tic, but it's defined more by that frequency and context of activity that makes it a tic disorder as opposed to just a normal movement. So tics tend to be most prevalent in the head and neck, although they can involve any body part.
  
  I guess one other feature of tics is the fact that they can also be very simple, just single movements or complex. And this tends to be individuals with a longer history of Tourette syndrome who may have tics that have strung together into a much more complex activity or complicated movement. Vocalizations can also be similar. They can be very simple in terms of just an exhalation or a sniff or cough to actual words and phrases.
  
  Melanie Cole: So let's talk a little bit about comorbid conditions. Have you seen that children with Tourette's often have these comorbid conditions such as OCD or attention deficit disorder? What other disorders are associated with Tourette syndrome?
  
  Dr. Leon Dure: I think that is something that I focus on quite a bit in my clinical practice, because I believe that the morbidity from Tourette syndrome is really dictated more by these other comorbid conditions. And it's true that obsessive compulsive behavior or obsessive compulsive disorder and anxiety are quite frequently seen in these patients as well as an attention deficit disorder.
  
  I think that other comorbidities have been reported that include things like depression, cognitive dysfunction, et cetera. But these are much less common than just more of a garden variety attention deficit disorder or obsessive and compulsive behavior.
  
  What is very interesting to me is how little that is appreciated prior to the visit with me. I may see the patient because they're referred for tics, but the frequency with which you find these anxiety-related features is striking.
  
  Melanie Cole: what an interesting field that you're in, doctor. So speak a little bit about treatment. When is treatment provided and why is it so hard to treat? Is this a very complex disorder? Tell us a little bit about what you do, what role medication plays, give us an overview of how you treat these children.
  
  Dr. Leon Dure: So for your listeners, I have to fully disclose that I have a very unique situation here. And so my treatment strategy may differ from what is encountered in other parts of the country. And to amplify on that, I am a pediatric neurologist with movement disorder training and I've been here for over 20 years. And so I basically serve the entire state and I see all these patients and I see them at a fairly young age.
  
  My belief is that the first step is education. I think that most younger children are in themselves not impaired or distressed by their tics. This is typically something that families worry about more. That's also a feature of the condition that this association with obsessive and compulsive behavior that tends to be a familial tendency. And so you can often identify the parent who may have some anxious tendencies because they are bothered much more by the tics than the child is. So I don't typically recommend any medical therapy or other type of therapy at an initial visit. Now, an older child who may be distressed due to behaviors that they can't control at school or that impair social function, these are things that do warrant an intervention.
  
  Now, traditionally people have talked about using medications, and there are a variety of medications that have been used. But the treatment effect is not exactly robust, if one thinks about how clinical trials have been carried out. And so earlier in my career, I became less enamored of a medical approach and began to adopt the cognitive behavior strategies for the management of tIcs, and this is a validated therapy that is quite helpful. And in our institution, this is done with a trained occupational therapist. And so this treatment works very well. And it's so effective that I seldom, if ever, have to use medication for management of tics.
  
  And I have to qualify this a little bit because I've only been speaking about treatment with regard to tics, but that tends to be the issue that people tend to focus on. I do believe that there is a significant role for pharmacologic management of obsessive and compulsive behavior as well as anxiety, again, if there is an associated distress or impairment.
  
  And then finally, it's very clear that the morbidity of kids with Tourette syndrome is so tightly related to their function, that attention deficit disorder has to be adequately managed, and that could be managed with again more standard techniques such as stimulants and other agents for management of that problem.
  
  Melanie Cole: Dr. Dure, what an interesting and comprehensive perspective that you have for this syndrome. Since the potential for stigmatization can be very high, as you mentioned a little bit briefly before about socialization, tell us about this development for a positive and supportive perspective on the part of the patients' families and even the school and the community, because as you said this can create quite high anxiety for the children that suffer from some of these symptoms.
  
  Dr. Leon Dure: Well, I think that I am benefited by the fact that I tend to see children at a fairly early age and I'm the first neurologist or any specialist to see most of these children. And part of my educational talk that I give to families is to indicate to them that at least at an early age, the tics are not a source of distress or impairment.
  
  And even though friends of children may be aware of these tics and they may ask questions about them, they really care more about how the child does otherwise. Are they a nice kid? Can they play sports? Are they good students? That type of thing. And I think the currency in childhood is not so much these issues relating to differences that they might be teased by, but rather the positive currencies that kids can exhibit.
  
  And what I've found is that children tolerate a lot of tics, believe it or not, both the individual as well as their peer groups. And I've had teenagers tell me that they did not feel the need for any type of therapy, because they themselves were involved in supportive social group, a supportive family, et cetera. So what I try to do is to get the family to reorient themselves away from tic expression and more towards, again, manage anxiety, manage school performance, and provide a positive environment for the child moving forward.
  
  Melanie Cole: So, as we wrap up, doctor, from the viewpoint of a pediatric neurologist who has served as the primary consultant for statewide population, how has this experience informed a more holistic approach and led to novel management strategies? What would you like to tell other providers when they have patients come to them with Tourette syndrome, with tics, with any of these comorbid conditions and why you feel it's so important that they look to the type of treatments you've been discussing today?
  
  Dr. Leon Dure: I think there's really just two main points I'd like to make. And one is that it is unfortunate that the degree of anxiety and obsessive compulsive behavior is fairly easy to miss if you don't ask the questions. And it's true that most primary care providers are not necessarily well trained in this and it's not their fault, but it is something that could probably be remedied. I think the familial aspects of this in terms of a tendency towards anxiety in other family members is something that also needs to be considered.
  
  I guess the last point I'd like to make is that even though I practice in a rural state in the south and this strategy that we've employed for the past 15 years or so is somewhat novel, it's been validated because the most recent practice parameter for the treatment and management of individuals with Tourette syndrome recommends a cognitive behavioral approach for management of tics as well as good deal of psychosocial education. So I feel like we've been on the right track and that this is something that people need to be aware of as a treatment modality.
  
  Melanie Cole: Great points. Thank you so much, doctor, for joining us today. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB MedCast. For more information on resources available at UAB Medicine, please visit our website at UABMedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.
  
  
• Hosts:Melanie Cole, MS