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Wednesday, April 8, 2015

Should My Son with Tourette's Syndrome Get Exposure Therapy for His School Anxiety?

From the Child Mind Institute

By Shelley Avny, Ph.D.
March 31, 2015

Treating his anxiety may also reduce his tics.

Question: Do you think my son with Tourette's needs exposure therapy with respect to school? My son also suffers from anxiety and mild OCD. He was supposed to sit for the secondary school exam (which seems to be a monster in his eyes) at the end of this year. However, he only made it to school for the first week.

His tics were really bad and he was placed on Haloperidol. He then started to develop new tics including "a twisted lock jaw tic" and total and partial body spasms. So we took him off, but the tics continued and grew.

Anything to do with school makes his tics worse. When he's calm, you know he's having tics but they are soft and calmer. His therapist suggested doing a neuropsychological assessment.


Answer: It sounds like anxiety is one of the primary triggers to your son's tics. What this means is that if the anxiety is effectively treated, you would likely see a secondary reduction in his tics.

Cognitive-behavioral therapy (CBT) is the most empirically supported treatment for anxiety disorders—and the "B" part of that frequently means exposure therapy.

We try to be really strategic in our approach to exposures because we want to make sure we're targeting the right source of anxiety without overwhelming the child. Therefore, we want to get a really good sense of what is making your son anxious. You're off to a great start in recognizing that it's school-related, but there could be a number of different situations within that.

Is it all about academic performance or is there a social component too? What are the feared outcomes? Is it a fear of failing? Messing up (being imperfect)? Disappointing others? Being held back a grade? Being perceived as "stupid"? Or something else?

This information is essential in structuring exposure therapy, because the idea is to "expose" him to the feared situation to help him see that a.) the outcome is likely not as bad as he was expecting, and b.) he can tolerate the anxiety that comes along with confronting the feared situation.

A therapist doing CBT will work with you and your son to develop a "hierarchy" of anxiety-provoking situations, and then help your son actually confront them. One thing to keep in mind is that, since the goal of exposures is to challenge the anxiety and your son's tics are triggered by anxiety, doing exposures may exacerbate his tics.

So, you want to make sure that he has had some treatment focusing on how to manage his tics, so that he will be prepared with the skill-set he needs when anxiety is elicited.

Finally, I'm wondering if an assessment was recommended because school is such an aversive experience for your son. When we see kids who have tremendous anxiety about school, some of the anxiety may be irrational but some of it may also be because school is actually a challenge for them.

Neuropsychological assessments help to determine if there are any cognitive impairments, language problems, or learning disorders that may explain the distress associated with school. Tourette's and OCD often co-occur with ADHD, so if your son is getting distracted in school, that could certainly interfere with his learning and make school a stressful environment for him.

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