Health Topics

General physicians (pediatricians, family practitioners, internists) are on the front line and manage most urgent and non-emergent medical problems in the office. The American Academy of Pediatrics practice guideline for Attention Deficit Hyperactivity Disorder (ADHD) states that the initial diagnosis, along with screening for other problems, and medical treatment of ADHD should be done at the primary physician's office.

• For most persons with ADHD and no other disorder, referral to a specialist for diagnosis or treatment is unnecessary.
• For individuals with TS and ADHD, where ADHD is causing the most impairment, treatment through a primary physician may be all that is needed.

For a variety of reasons, in the Unites States, much health care is provided by specialist physicians. Similar to general physicians, specialist physicians complete a bachelor's degree followed by four years of medical school, then do a medical residency.

Usually the first two to three years of residency are in a general area, like internal medicine or pediatrics. This is followed by an additional residency or fellowship of three or more years that allows the specialist to become a focused expert, while ensuring an adequate level of general medical knowledge. There are some programs, in psychiatry or radiology, for example, where a physician may begin a specialty residency after just one year of general medicine.

Neurosurgeons treat or cure brain problems by removing an abnormal area of brain. Functional neurosurgeons may insert electrical devices, like deep brain stimulators, to alter brain function. Currently, deep brain stimulation in Tourette Syndrome is experimental.

The Tourette Syndrome Study Group is applying to the National Institutes of Health to perform a very high quality study of deep brain stimulation for severe TS symptoms in adults. Therefore, we recommend that patients only consider DBS in an approved research protocol at this time.

• So, in general, the vast majority of individuals with TS would not need to see a neurosurgeon.

Neurologists treat brain diseases and disorders medically. Medications mainly treat the symptoms, but not the cause(s) of the problem. This is because most diseases and disorders of the brain are either genetic or have other causes that are unknown. However, patients with TS can often be treated medically with some benefit.

Within neurology, there are general neurologists and sub-specialists. Typically, Pediatric Neurologists complete a two year pediatric residency followed by a three-year neurology residency. This includes training in the diagnosis and treatment of tics as well as learning and behavior problems. Movement Disorder Neurologists focus on problems with voluntary and involuntary movement, including tics, and are generally accustomed to seeing and treating problems with thoughts, mood/anxiety, and attention. The degree to which neurologists are willing, interested, and/or able to address learning, behavior, and mood problems varies widely.

• See a neurologist if tics or other neurologic symptoms are the primary problem, or if the neurologist is willing to treat additional problems such as ADHD and Obsessive Compulsive Disorder (OCD).

Psychiatrists may be trained in pediatric or adult-oriented programs. Psychiatrists medically treat brain disorders affecting mood or thoughts, for example, major depression, bipolar disorder, schizophrenia, and anxiety disorders, including OCD. Because anxiety and depression are so common, primary (general) physicians often will treat these to a point before referring to a psychiatrist. Bipolar Disorder or Schizophrenia should be referred to psychiatry right away. Psychiatrists may also do therapy, but often delegate this to other providers.

• See a psychiatrist for a medical consultation if bipolar disorder, hallucinations, or psychosis are suspected or known to be present, or if severe anger, aggression to self or others, anxiety, or depression are present.

Once a diagnosis is made and medical treatment initiated by a general physician or specialist, medical follow-up may consist of brief, important visits to check for side effects and to determine whether the medication is helpful. Usually, improvement in symptoms will be partial, and many other problems will remain which medical doctors may not have the training to address.

Doctors of psychology most often have a PhD or a PsyD, achieved through postgraduate programs that last four or more years after college. These programs include rigorous formal education and several years of mentored, practical training. PhDs also perform substantial research for a doctoral dissertation.

Psychologists are trained to provide specific types of interventions, which can be just as effective as medication in certain individuals. An example would be cognitive behavioral therapy which is proven effect for OCD. The National Institutes of Health is funding a study to determine whether a certain kind of psychological therapy is effective for reducing tics. For individuals and families affected by TS, the role of the psychologist is sometimes the most important role. Psychologists also have the training to understand family dynamics and assist with issues related to coping with stress and anger management, which are critical to improving quality of life in individuals with TS.

• See a psychologist for help with coping with the TS diagnosis or other stressors, anger management, parenting and discipline issues, and therapy for OCD,

In closing, it is important to remember that every individual has different needs, thus the type of treatment and doctor will vary, and more than one type of doctor may be needed. Other types of doctors, such as developmental pediatricians, behavioral neurologists, or physiatrists, may also play a role.

• If you or a family member would like to see a doctor familiar with TS, you may call the Tourette Syndrome Association at 718-224-2999 or email ts@tsa-usa.org, to find someone in your area.
• If a doctor you see has been knowledgeable and helpful, encourage him or her to call TSA and apply to be an approved provider.