CASE STUDIES

Case study one

JARROD , 12 , presents with a 3-4-year history of vocal and motor tics , which have become particularly problematic over the past few months . His symptoms include eye twitching , neck jerks , shoulder shrugs , arm twisting , snorting , throat-clearing and squealing . His tics occur multiple times every day . Although they occur much less at school , he often has severe and explosive tics after school . A couple of classmates have recently asked him why he makes strange noises , causing him embarrassment . He has also become highly obsessional , needing to organise his possessions in a particular way and completing tasks , such as bedtime routines , in a highly ritualised manner .

He has recently started to display defiance and anger towards his parents and 10-year-old sister . There is also a lot of negative self-talk — for example , “ I ’ m useless ; I shouldn ’ t even be here .”

Jarrod had delayed early language development and was diagnosed with ADHD at age eight . He took stimulant medication for some months but experienced side effects and so stopped . He is in year six and is functioning about 12 months behind his peers academically . His parents are worried about his transition to high school next year .

He has always been an anxious and emotionally intense boy and has struggled to make friends . He finds it hard to fall asleep , although this has improved with melatonin , which his parents get over the internet .

Jarrod loves football and video games , such as Minecraft and Fortnite . His parents find it hard to shift him away from these games .

He saw a psychologist several

times last year in relation to anxiety and anger management . His parents try to restrict food additives , gluten and dairy as they believe these contribute to his problems .

The family history is notable for Jarrod ’ s mother having had longterm

struggles with depression , anxiety and OCD and his father being diagnosed with ADHD two years ago .

On examination , Jarrod is a tall , thin boy who appears anxious . He is wearing a baseball cap and has poor eye contact . He is clearly uncomfortable talking to the GP and does not smile during the consultation . The GP observes some neck jerks and shoulder shrugs and hears some high-pitched inspiratory sounds .

The GP diagnoses GTS with associated obsessive compulsive behaviours . Features of anxiety and depression are also noted . The tics are identified as the management priority . He is referred to the psychologist to address the anxiety and defiance and also to a paediatrician to consider medication treatment for the GTS . The GP also raises concerns about the risk of technology addiction and provides advice regarding managing this , as well as sleep hygiene .

Jarrod re-engages with the psychologist , who provides individual therapy for his anxiety and self-image . The paediatrician gathers information from the school , which verifies his tics , social difficulties and ongoing symptoms of ADHD . At his second appointment with the paediatrician , Jarrod is started on a trial of clonidine to help with the tics and ADHD . Over the next few months , his tics fluctuate but are generally less severe ; however , his anxiety becomes more problematic . The paediatrician adds fluoxetine to treat the anxiety .

Case study two

Marco , 10 , has had vocal and motor

tics for about 18 months . These have been severe and impairing . He has had a persistent neck tic and experiences pain in his neck that his mother believes is because of constantly trying to suppress this tic . He is very embarrassed by his tics , to the extent that he refuses to go to school .

Marco is highly intelligent and achieves above grade level academically . He used to be very sociable but has become much less so this year , which he says is because of his tics .

At home , he has been extremely angry , frequently yelling and swearing at his parents and using obscene gestures . His parents are not sure if some of these behaviours are tics or just expressions of his frustration . He has been refusing to leave the house or join in family activities .

Marco saw a child psychiatrist , who diagnosed GTS and prescribed risperidone , which made him appear ‘ zoned out ’. He was less communicative and gained weight . His tics were only slightly reduced , so his parents stopped the medication after around six weeks .

They are very reluctant to try any other medications .

The GP searches for a psychologist with specialised expertise in GTS . The TSAA helps identify a local psychologist trained in CBIT . Marco takes a while to engage but ultimately does and benefits from the program .

Family therapy is suggested to address some of the difficulties in family dynamics , but the family chooses not to pursue this at this point .