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.