Dr. Peter Bingham reflects on the type of visit he participates in at the Pediatric Neurology Clinic at The University of Vermont Children’s Hospital – the patient, the family, the questions that come up, and the answers that are pursued for a healthier patient.
Though Tom’s parents have brought him in because of motor tics, by the end of the visit, I don’t think that tics are the main thing bothering him.
Why? For one thing, it turns out that, in the kind of sequence that makes parents wonder if the doctor will even believe them, Tom’s tics have miraculously stopped in the month since the appointment was made. Appearing from nowhere last summer, Tom’s tics were sudden, head shaking movements, happening any time of day. His father notices Tom suddenly turning his head and making a grunting sound. Sometimes he can feel the movements ‘coming on,’ but usually he doesn’t notice them as much as other people seem to. If he thinks about it, he feels like he can stop the tics, at least for a while.
Tom also has attention deficit (ADHD), and some learning differences. His primary doctor recommended a medicine for that, but it made him anxious and aggressive, so it was stopped. His parents aren’t too keen on medicine right now. As we talk about his tics, and ADHD symptoms, Tom gets a little defensive, as though he was getting accused of doing something wrong. To me, this says something about how his family reacts to Tom’s tics and impulsiveness, and it isn’t the only time he seems to feel wrongly blamed, misunderstood.
Tom is unhappy with being in “a special class,” where his teacher often seems disappointed in him. He seems resigned when I wonder if he can come to a better understanding with this teacher. Like many children with attention problems, Tom often has a hard time owning up to his mistakes when he steps over the rules. This is a tough situation—since Tom feels like his good intentions aren’t appreciated, it’s hard for him to take responsibility when he’s wrong, as though owning up might make him responsible for dozens of un-deserved “blames.”
I wonder how many teachers and students, parents and children, find themselves stuck at this kind of diplomatic impasse. This family needs some questions answered, maybe even some they’re not asking: where did these tics come from, and where will they go? Is a medicine needed? What else can be done to stop the tics? What about Tom’s feeling misunderstood? Tics are common. About 10 percent of kids–especially boys–have them, usually for just a few months or years. Like most kids’ tics, Tom’s tics aren’t a symptom of some underlying disease, but they are often associated with attention problems.
In pediatric neurology, we rarely recommend medication—only if tics get very intense and bother the child. The key is education for others around Tom to ignore them, so that the tics don’t end up bothering Tom just because they bother others. A different ADHD medicine might be helpful, but it’s true that these medicines may (temporarily) worsen tics.
For ideas about how to help someone with ADHD, I suggest Russell Barkley’s Taking Charge of ADHD, and consideration of a behavior self-management program offered by our Psychology department for children with tics. For Tom, I suggest Jack Gantos’ marvelous Joey Pigza Swallowed the Key.
When I ask Tom if I could talk with his teacher, he hangs his head and says no, softly, under his breath. I think Tom doesn’t want, once again, to be the ‘special case’ – now with a specialist doctor who wrangles school matters with the teacher for him; it shows a noble impulse on Tom’s part: he wants to take responsibility, to fend for himself, to deal with school without my ‘pulling strings’ on his behalf. I want to tell Tom I respect this. Even more, I want to tell him that all of us can use some help.
Peter Bingham, MD, is a pediatric neurologist at the University of Vermont Children’s Hospital at the University of Vermont Medical Center. He is also a professor of Neurology and Pediatrics at the Larner College of Medicine at UVM.