A 12-year-old female child, the eldest of two siblings and a student of
class 7, belonging to an upper-middle class nuclear family, presented to
a tertiary care facility in south India via online consultation in
February 2020 with complaints of irresistible gestures and odd sounds
that were produced involuntarily and persisted for a period of one to
two minutes. With only one episode per day, these episodes happened
three to four times every week.
Her peers initially noticed the sounds and gestures in class, and
perceived it as verbally abusive behaviour and reported it to the class
teacher, who took the child to the sick room, where she had specific
peculiar involuntary motor movements involving her upper limb along with
vocal tics such as clearing of the throat. All episodes occurred when
the child was at school, as the parents were not initially observant of
the tics.
The school administration suggested that the child require medical
attention from the school’s on-site health team involving a psychiatrist
and psychologist, who met with the parents and the child. After ruling
out organic causes with a thorough neurological examination, and medical
and radiological investigations, the diagnosis of Tourette’s disorder
with co-morbid depression was made. However, the parents believed there
were linguistic and cultural barriers because the school medical team
was from a different country than the child and her family. In addition,
they found it challenging to proceed with the same team for treatment,
so they sought an online consultation from our team.
The parents and the child were psychoeducation about the illness.
Comprehensive behavioural intervention therapy (CBiT) was chosen because
of the ongoing COVID pandemic and the family’s preference for a
non-pharmacological mode of treatment. After taking informed consent for
online CBiT, sessions with the index child were scheduled weekly with
the mother as the co-therapist. The initial sessions involved detailed
history-taking. Apart from tics, history also indicated that the child
had displayed reclusive behaviour and a deterioration in academic
performance after her father’s haemorrhagic stroke in January 2019. The
symptoms of depressed mood, decreased appetite, decreased psychomotor
activity, and feelings of helplessness and worthlessness were suggestive
of comorbid depression. No past or family history suggestive of any
psychiatric, behavioural illness, or other medical conditions were
present. No family history of substance was present.
During the mental status examination, a rapport was built with the
child. The patient discussed her low academic performance, anxiety about
her father’s health, and the absence of suitable social support from her
mother and school. The patient scored 24 on the Yale Global Tic Severity
Scale (YGTSS) at that time, indicating moderate tic disorder, and a
score of 3 on the Clinical Global Impressions Scale (CGI), suggesting
mild illness severity. The child demonstrated a need for parental
attention and acceptance on the Children’s Apperception Test (CAT) and
anxiety over rejection and abandonment. The primary evidence in favour
of the thesis was reaction formation and regression. The child was
average in her studies, as confirmed by Malin’s intelligence scale for
children (MISC).
Therapy was first targeted to control general anxiety and depressive
symptoms, and then vocal tics and upper extremity movement tics were
treated. The patient complied well with the therapy and did as she was
told when given directions.
Initially, the motor tics were targeted (SUD: 75), and once their SUD
started decreasing, vocal tics were also targeted. The course of
improvement in tics with SUD values is given in Table 1.