Treating Tourette's, OCD, and Selective Mutism in Children

Specialty behavioral treatments can benefit children with specific problems.

Posted Sep 21, 2015

When Lucas was in third grade, his parent first noticed his tics. They wondered if it was Tourette's Syndrome (TS), since he had fluctuating involuntary arm jerks and other physical tics, plus a vocal tic consisting of mouth noises or inappropriate words. "But we were frustrated with finding a doctor who knew about TS," his mother said (she told her story on the Tourette Association of America website). "The tics got worse; then we finally got a diagnosis when he was in the fourth grade."

“Treatments were trial and error. Over four years we tried medication, which was a negative experience, and nutrition and diets, with no change. We also tried neuro-feedback which was helpful for a short time, but with no lasting improvement."

Fortunately they had a friend who introduced them to a new treatment—CBIT, Comprehensive Behavioral Intervention for Tics. It's a type of behavior therapy that teaches people to recognize each tic along with any sensation that preceded it, and practice competing movements that prevent it or make it less conspicuous. This method requires several assessments, educational treatment, and other steps. CBIT was of great benefit to Lucas and his family.

TS is only one of several tic disorders. Its symptoms tend to peak in early childhood and decline in teens and adults. Its treatment by CBIT is the subject of studies described by the Tourette Association of America website. A clinical trial found it to provide significant symptom improvement in slightly over half, but not all, of the children tested. Names of CBIT providers can be accessed by contacting this website. 

Jonathan Comer and David Barlow, a leader in psychological treatments based on evidence, described TS as one of the psychological conditions of children that may require a specialized behavioral approach not shared by most clinicians.

TS has a neurological basis, which is why it is generally diagnosed by neurologists. The origins of TS have been proposed but not fully understood. Involuntary movements can originate in the frontal lobe of the brain, but are controlled by the basal ganglia and thalamus, structures well below the brain's surface, that may block some movements but let others go ahead. A deficit in this filter mechanism may result in unwanted movements. Dopamine is a neurotransmitter that connects nerve cells in this filtering process, and its activity is a target of often-prescribed medications. Despite the neurological basis of TS, the behavior therapy approach can be an important part of treatment.

samhsa.gov/Wikimedia Commons

Howie Mandel is a gifted comedian and television host who has had both TS and OCD.

Source: samhsa.gov/Wikimedia Commons

Obsessive compulsive disorder or OCD can be characterized by repetitive, unnecessary activities, or compulsions (like lining up dishes over and over so they look "perfect.") The obsessive part often involves a repetitive thought that leads to discomfort, especially if a ritual is not performed in a certain way. Cognitive-behavioral treatments are available that use gradual exposure and response prevention, as well as several other components provided by some but not all mental health professionals.

Selective Mutism is associated with anxiety and expressed by not speaking in certain situations. For Kaitlyn, a bright second-grader who spoke at home but not at school, an empathic school counselor set behavioral goals and encouraged gradual, step-by-step progress toward speaking in school (names and examples are fictionalized). For other children, a behavioral plan may be provided by a child psychologist or other therapeutic professional, or the kind of intensive treatment provided by a therapeutic camp, such as Confident Kids in Michigan or Mighty Mouth Kids in New York.

Before starting treatment, you can ask the psychologist or other therapist if they practice CBT in general and these specialized methods in particular, and whether they provide practice assignments between sessions—a good sign. You can also find workbooks for parents and guides for professionals that are educational without substituting for individualized medical or psychologial treatment. 

So the examples given here are not meant as medical or psychotherapeutic advice, which is best provided face-to-face by a qualified medical or psychological professional who can assess and treat each individual child. These examples are intended to provide options for parents and professionals to explore. Unfortunately, these specialized treatments are not accessible in many areas, so telehealth supervision or therapy has been suggested as a way to make treatment more widely available in the future. Otherwise, traditional treatment may be an adequate alternative.

But if they are available, the specialized methods described here offer new possibilities for children's behavioral treatment. 

Resources

www.tsa-usa.org

www.selectivemutism.org

References

Comer, J. and Barlow, D. (2014). The occasional case against broad dissemination and implementation: Retaining a role for specialty care in the delivery of psychological treatments. Am. J. Psychol. 69:1-18 March, J. and Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual. New York: Guilford Press. Woods, D. and others (2008). Managing Tourette Syndrome: A Behavioral Intervention Workbook, Parent Workbook (Treatments That Work). Oxford University Press. Woods, D. and others (2008). Managing Tourette Syndrome: A Behavioral Intervention for Children and Adults Therapist Guide (Treatments That Work). Oxford University Press.