**4.3 Treatment of tics associated with streptococcal infection**

The ''Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS)'' hypothesis suggested that chronic, recurrent tics and OCD can arise as an autoimmune sequel of infection with group A beta-hemolytic streptococcus45. Actually, there is insufficient evidence to conclude that streptococcal infection has a true

Epidemiology of Tics 169

Associated OCD can be more disabling than the tics themselves and may create a state of tension and anxiety that heightens tic severity. Cognitive behavioral therapy performed by a well-trained and experienced therapist can be a very effective non-pharmacological treatment for OCD. Selective serotonin reuptake inhibitors (SSRIs) are considered the firstline medications for OCD. Combination with an atypical antipsychotic may be helpful for cases resistant to an SSRI alone. DBS involving the internal capsule/nucleus accumbens is under investigation as a therapy more severe and medication-refractory cases of OCD.

The Tourette Syndrome Association (TSA) is an informative reference guide to patients, parents, and teachers, because it clearly outlines many home and school psychoeducational modifications and interventions that may be effective for children with ADHD and tics. There are local support groups in many cities that can provide information, guidance, and

The optimum management of patients with tics involves a comprehensive approach that focuses not only on the tics themselves, but also on neuropsychiatric comorbidities (particularly ADHD and OCD) and existing psychosocial stressors. For young patients, major goals of treatment include helping the child to develop self-confidence, personal resilience, and positive psychosocial skills. A critical goal is to reduce obstacles to successful learning and socialization. The ultimate management usually requires a spectrum of interventions that may include education, cognitive-behavioral therapies, counseling, and medications. DBS might prove to be a useful therapy for patients with severe, disabling

Education of parents, teachers and peers is a critical initial intervention. Patients and their parents should be informed that it is appropriate explain to others that they have tics, that they cannot control certain movements or sounds, provide patients and parents with current information about the causes of tics such as genetic factors, brain neurochemical imbalances, emphasize that they are not signs of psychological or emotional illness, a common misperception, explain how tics change in type over time and that they naturally fluctuate in

A majority of GTS patients experience improvement of tics in late adolescence or early

Education is often needed for school personnel because there are many misperceptions of tics as being voluntary, attention-seeking or purposely disruptive behaviors. It is recommended that special accommodations be considered in the school setting, like excusing the child, at his or her request, to the nurse's office to release tics or providing additional time in a separate room when taking school tests. Such provisions should be

As expected in behavior-analytic research, direct observation has been the preferred method for quantifying tic severity. However, researchers in psychiatry, neurology, and even the

mandated in the countries under laws protecting individuals with disabilities.

**4.7 Treatment of OCD** 

support.

tics, or OCD.

severity.

**5. Studies about tics** 

**4.8 Educating the patient, family and school** 

adulthood. So the prognosis of TS could be quite good.

etiological role in causing tics. Children with documented streptococcal infections be treated with an appropriate course of antibiotics, but that treatment with chronic antibiotics or immune-modifying therapies like plasma exchange or intravenous immuneglobulin are not justified based on existing evidence.
