Volume 16, Number 4
Tic Tactic
For Tourette's and chronic tics, a new approach.
"Stop chewing on your fingers!" What was memorable about "Johnny's" first grade was his teacher's demands and the well-meaning but hurtful questions of his classmates: "Why do you stick your hand in your mouth so much?" His action was a cover for the more embarrassing behavior, tongue-thrusting, which he was powerless to stop. Fortunately, the child's chronic tic disorder was easily diagnosed. Unfortunately, the medicine he was given -- haloperidol, an effective neuroleptic drug -- caused such fatigue he napped all the time.
"Medication for chronic tics is useful and necessary," says pediatric psychiatrist
John Walkup, M.D., "but some children can't tolerate the side effects.
So we're exploring alternatives. There's gathering evidence that, for tics,
a behavioral approach may also help." This summer, Walkup began enrolling
children for a 120-child, NIH-funded study of comprehensive behavioral intervention
for tics (CBIT).The technique includes guidance for parents in what makes tics better or worse, relaxation tactics and strategies to decrease a child's tic severity -- all strongly grounded in behavioral theory. "And because our patients often create personal strategies to deal with their tics, we've also integrated appropriate ones in our approach," says Walkup.
CBIT centers, in part, on the fact that tics are preceded by an urgent feeling -- the premonitory sensation. "Most kids, at first, aren't aware of it or even of the fact that they're ticcing until someone calls it to their attention." But they all too quickly have the tic pointed out. Then, says Walkup, the teasing and stigmatizing typically follow. Not surprisingly, children not only become exquisitely sensitive to their premonitory sensations, but they also begin to fear them. The worse a tic makes them feel, the more anxious they become with reminders it's on its way. "There's a classic negative reinforcement cycle," Walkup explains, where the only relief from the urge, though short-lived, is the tic itself.
CBIT aims to disrupt the negative cycle much in the way you put a paper collar on a dog to keep "itch" from becoming "scratch." In Johnny's case, says Walkup, we provided a substitute activity for his wayward fingers. "He learned to put his hand over his mouth when he felt the urge to tic, like covering a cough. It was something more socially acceptable. It decreased the stigma and interrupted the negative reinforcement cycle.
"We also told the boy's teacher to back off and trained his parents to identify potential tic-triggering situations.
"What we're doing isn't revolutionary," says Walkup. "It doesn't directly correct wayward brain biology, as does drug therapy." But it does work on environmental aspects that come between brain and behavior, he says. "Our understanding of this has become much more sophisticated. We saw possibilities we couldn't ignore."
For more information, call 410-614-4236.