676 CHAPTER 14
before urinating in the bed. That is, the child learns to detect the sensations of a full
bladder even during sleep.
Although children may willfully refuse to use the toilet (which could be a symp-
tom of oppositional defi ant disorder; Christophersen, 1994) or have severe anxiety
about using the toilet, both enuresis and encopresis usually arise from biological
factors. Consultation with the child’s pediatrician and implementation of the recom-
mended strategies often resolve these disorders. Children with elimination problems
may come to the attention of a mental health professional because the parents are
worried not only about the problem itself but also that it may be a sign of another
type of problem, such as oppositional defi ant disorder, signifi cant anxiety, or sexual
abuse (perhaps by a child care provider).Tic Disorders
Aticis rapid but repetitive involuntary movement or vocalization. Many people
develop some kind of tic—they may have an episodic but persistent eye blink or
shoulder shrug (motoric tics), or a recurrent “hmmm” of throat clearing or grunt-
ing sound (vocal tics). Tics are relatively common in children, but a tic disorder
may be diagnosed when the tic (motor or vocal) is persistent and occurs many
times a day on most days. In fact, up to 12% of children between 6 and 15 years
old have a tic disorder at some point in their lives (Khalifa & von Knorring, 2003;
Zhu et al., 2003).
One tic disorder is Tourette’s disorder (also referred to as Tourette syndrome),
named for the psychiatrist Gilles de la Tourette (1857–1904), who fi rst described the
constellation of symptoms. Tourette’s disorder involves recurrent motoric and vocal
tics. A rare type of vocal tic is the involuntary shouting of obscenities (referred to as
coprolalia); only 10% of people with Tourette’s disorder exhibit coprolalia (American
Psychiatric Association, 2000).
Tic disorders are generally evaluated and treated by a neurologist. Children with
these disorders can come to the attention of a mental health professional because
parents may be concerned that the symptoms either represent willful oppositional
behavior (as in oppositional defi ant disorder) or are a manifestation of anxiety.
A tic may be diffi cult to distinguish from a stereotyped behavior that arises
as part of a pervasive developmental disorder. However, stereotypies gener-
ally seem intentional and rhythmic, and they appear to soothe the individual
exhibiting the behavior. In contrast, tic behaviors generally arise in clusters,
and although they may sometimes feel voluntary, they are typically involun-
tary. Tics can also be diffi cult to distinguish from compulsions, especially if comorbid
obsessive-compulsive disorder (OCD) is present. However, the compulsive behaviors
of OCD are usually more elaborate and also more normal-seeming than a tic, and
they are associated with corresponding obsessions. Vocal tics should be distin-
guished from the psychotically disorganized speech that is associated with schizo-
phrenia: In the absence of other disorganized or psychotic behavior, a tic disorder is
the more likely diagnosis.
Depending on the individual and the type and severity of tics, the effects can
range from no distress or impaired functioning to severe distress and/or impaired
functioning. Young children may not be aware of their tics and usually do not expe-
rience distress or impaired functioning, in part because their peers do not call atten-
tion to their problem. For older children and adults, the more noticeable the tics, the
more social rejection they may experience and the more self-conscious and ashamed
they are likely to become, perhaps leading them to avoid social interactions when-
ever possible. Frequent tics or those that involve complex behaviors (such as deep
knee bends) may interfere with normal functioning. In such cases, medication for
the tic disorder may decrease the frequency and intensity of the symptoms (Davies
et al., 2006; Shavitt et al., 2006). Behavioral treatment for tics may help patients
increase their ability to control the behaviors for short periods of time (Carr &
Chong, 2005; Cook & Blacher, 2007; Phelps, Brown, & Power, 2002).Tic disorders
A set of disorders characterized by persistent
tics (motor or vocal) that occur many times a
day on most days.
Tourette’s disorder
A tic disorder characterized by recurrent
motoric and vocal tics; also referred to as
Tourette syndrome.