PANDAS, is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections.
The term is used to describe a subset of children who have Obsessive Compulsive Disorder (OCD) and/or tic disorders such as Tourette's Syndrome, and in whom symptoms worsen following strep. infections such as "Strep throat" and Scarlet Fever.
The children usually have dramatic, "overnight" onset of symptoms, including motor or vocal tics, obsessions, and/or compulsions. In addition to these symptoms, children may also become moody, irritable or show concerns about separating from parents or loved ones. This abrupt onset is generally preceeded by a Strep. throat infection.
What is the mechanism behind this phenomenon? At present, it is unknown but researchers at the NIMH are pursuing a theory that the mechanism is similar to that of Rheumatic Fever, an autoimmune disorder triggered by strep. throat infections. In every bacterial infection, the body produces antibodies against the invading bacteria, and the antibodies help eliminate the bacteria from the body. However in Rheumatic Fever, the antibodies mistakenly recognize and "attack" the heart valves, joints, and/or certain parts of the brain. This phenomenon is called "molecular mimicry", which means that proteins on the cell wall of the strep. bacteria are similar in some way to the proteins of the heart valve, joints, or brain. Because the antibodies set off an immune reaction which damages those tissues, the child with Rheumatic Fever can get heart disease (especially mitral valve regurgitation), arthritis, and/or abnormal movements known as Sydenham’s Chorea or St. Vitus Dance.
In PANDAS, it is believed that something very similar to Sydenham’s Chorea occurs. One part of the brain that is affected in PANDAS is the Basal Ganglia, which is believed to be responsible for movement and behavior. Thus, the antibodies interact with the brain to cause tics and/or OCD, instead of Sydenham Chorea.
Frequently Asked Questions
Q. Is there a test for PANDAS?
A. No. The diagnosis of PANDAS is a clinical diagnosis, which means that there are no lab tests that can diagnose PANDAS. Instead clinicians use 5 diagnostic criteria for the diagnosis of PANDAS (see below). At the present time the clinical features of the illness are the only means of determining whether or not a child might have PANDAS.
Q. What are the diagnostic criteria for PANDAS?
A. They are:
1. Presence of Obsessive-compulsive disorder and/or a tic disorder
2. Pediatric onset of symptoms (age 3 years to puberty)
3. Episodic course of symptom severity
4. Association with group A Beta-hemolytic streptococcal infection (a positive throat culture for strep. or history of Scarlet Fever.)
5. Association with neurological abnormalities (motoric hyperactivity, or adventitious movements, such as choreiform movements)
Q. What is an episodic course of symptoms?
A. Children with PANDAS seem to have dramatic ups and downs in their OCD and/or tic severity. Tics or OCD which are almost always present at a relatively consistent level do not represent an episodic course. Many kids with OCD or tics have good days and bad days, or even good weeks and bad weeks. However, patients with PANDAS have a very sudden onset or worsening of their symptoms, followed by a slow, gradual improvement. If they get another strep. infection, their symptoms suddenly worsen again. The increased symptom severity usually persists for at least several weeks, but may last for several months or longer. The tics or OCD then seem to gradually fade away, and the children often enjoy a few weeks or several months without problems. When they have another strep. throat infection the tics or OCD return just as suddenly and dramatically as they did previously.
Q. Are there any other symptoms associated with PANDAS episodes?
A. Yes. Children with PANDAS often experience one or more of the following symptoms in conjunction with their OCD and/or tics:
1. ADHD symptoms (hyperactivity, inattention, fidgety)
2. Separation anxiety (Child is "clingy" and has difficulty separating from his/her caregivers. For example, the child may not want to be in a different room in the house from his/her parents.)
3. Mood changes (irritability, sadness, emotional lability)
4. Sleep disturbance
5. Night- time bed wetting and/or day- time urinary frequency
6. Fine/gross motor changes (e.g. changes in handwriting)
7. Joint pains
Q. My child has had strep. throat before, and he has tics and/or OCD. Does that mean he has PANDAS?
A. No. Many children have OCD and/or tics, and almost all school aged children get strep. throat at some point in their lives. In fact, the average grade-school student will have 2 – 3 strep. throat infections each year. PANDAS is considered when there is a very close relationship between the abrupt onset or worsening or OCD and/or tics, and a preceding strep. infection. If strep. is found in conjunction with two or three episodes of OCD/tics, then it may be that the child has PANDAS.
Q. Could an adult have PANDAS?
A. No. By definition, PANDAS is a pediatric disorder. It is possible that adolescents and adults may have immune mediated OCD, but this is not known. The research studies at the NIMH are restricted to children.
Q. My child has PANDAS. Should he have his tonsils removed?
A. The NIH does not recommend tonsillectomies for children with PANDAS, as there is no evidence that they are helpful. If a tonsillectomy is recommended because of frequent episodes of tonsillitis, it would be useful to discuss the pros and cons of the procedure with your child’s doctor, because of the role that the tonsils play in fighting strep. infections.
Q. What exactly is an anti-streptococcal antibody titer?
A. The anti-streptococcal antibody titer determines whether there is immunologic evidence of a previous strep. infection. Two different strep. tests are commercially available: the antistrepolysin O (ASO) titer, which rises 3-6 weeks after a strep. infection, and the antistreptococcal DNAase B (AntiDNAse-B) titer, which rises 6-8 weeks after a strep. infection.
Q. What does an elevated anti-streptococcal antibody titer mean? Is this bad for my child?
A. An elevated anti-strep. titer (such as ASO or AntiDNAse-B) means the child has had a strep. infection sometime within the past few months, and his body created antibodies to fight the strep. bacteria. Some children create lots of antibodies and have very high titers (up to 2,000), while others have more modest elevations. The height of the titer elevation doesn’t matter. Further, elevated titers are not a bad thing. They are measuring a normal, healthy response – the production of antibodies to fight off an infection. The antibodies stay in the body for some time after the infection is gone, but the amount of time that the antibodies persist varies greatly between different individuals. Some children have "positive" antibody titers for many months after a single infection.
Q. When is a strep. titer considered to be abnormal, or "elevated"?
A. The lab at NIH considers strep. titers between 0-400 to be normal. Other labs set the upper limit at 150 or 200. Since each lab measures titers in different ways, it is important to know the range used by the laboratory where the test was done – just ask where they draw the line between negative or positive titers.
It is important to note that some grade-school aged children have chronically "elevated" titers. These may actually be in the normal range for that child, as there is a lot of individual variability in titer values. Because of this variability, doctors will often draw a titer when the child is sick, or shortly thereafter, and then draw another titer several weeks later to see if the titer is "rising" – if so, this is strong evidence that the illness was due to strep. (Of course, a less expensive way to make this determination is to take a throat culture at the time that the child is ill.)
Q. Should an elevated strep. titer be treated with antibiotics?
A. No. Elevated titers indicate that a patient has had a past strep. exposure but the titers can not tell you precisely when the strep. infection occurred. Children may have "positive" titers for many months after one infection. Since these elevated titers are merely a marker of a prior infection and not proof of an ongoing infection it is not appropriate to give antibiotics for elevated titers. Antibiotics are recommended only when a child has a positive rapid strep. test or positive strep. throat culture.
Q. What are the treatment options for children with PANDAS?
A. The treatments for children with PANDAS are the same as if they had other types of OCD or tic disorders. Children with OCD, regardless of whether or not their illness is strep. triggered, benefit from cognitive behavioral therapy and/or anti-obsessional medications. A recent study showed that the combination of an SSRI medication (such as fluoxetine) and cognitive behavioral therapy was the best treatment for OCD, and that medication alone or cognitive behavioral therapy alone were better than no treatment, or use of a placebo (sugar pill). It often takes time for these treatments to work, so the sooner therapy is started, the better it is for the child.
Children with strep. triggered tics should be helped by the same tic medications that doctors use to treat other tic disorders. Your child’s primary physician can help you decide which type of specialist your child may need to see to receive these treatments.
Q. Can penicillin be used to treat PANDAS or prevent future PANDAS symptom exacerbations?
A. Penicillin and other antibiotics kill streptococcus and other types of bacteria. The antibiotics treat the sore throat or pharyngitis caused by the strep. by getting rid of the bacteria. However, in PANDAS, it appears that antibodies produced by the body in response to the strep. infection are the cause of the problem, not the bacteria themselves. Therefore one could not expect antibiotics such as penicillin to treat the symptoms of PANDAS. Researchers at the NIMH have been investigating the use of antibiotics as a form of prophylaxis or prevention of future problems. At this time, however, there isn’t enough evidence to recommend the long-term use of antibiotics.
Q. What about treating PANDAS with plasma exchange or immunoglobulin (IVIG)?
A. The results of a controlled trial of plasma exchange (also known as plasmapheresis) and immunoglobulin (IVIG) for the treatment of children in the PANDAS subgroup was published in "The Lancet", Vol. 354, October 2, 1999. All of the children participating in the study had clear evidence of a strep infection as the trigger of their OCD and tics, and all were severely ill at the time of treatment. The study showed that plasma exchange and IVIG were both effective for the treatment of severe, strep. triggered OCD and tics, and that there were persistent benefits of the interventions. However, there were a number of side-effects associated with the treatments, including nausea, vomiting, headaches and dizziness. In addition, there is a risk of infection with any invasive procedure, such as these. Thus, the treatments should be reserved for severely ill patients, and administered by a qualified team of health care professionals. The NIH is not currently conducting any trials with immunomodulatory therapies, and so is not able to offer either or the treatments.
Of note, a separate study was conducted to evaluate the effectiveness of plasma exchange in the treatment of chronic OCD (Nicolson et al: An Open Trial of Plasma Exchange in Childhood Onset Obsessive-compulsive Disorder Without Poststreptococcal Exacerbations. "J Am Acad Child Adolesc Psychiatry 2000," 39[10]: 1313-1315. None of those children benefited, suggesting that plasma exchange or IVIG is not helpful for children who do not have strep. triggered OCD or tics. Source NIH.
Wednesday, March 25, 2009
What is Tourette syndrome
Tourette syndrome (TS) is a neurological disorder characterized by repetitive, stereotyped, involuntary movements and vocalizations called tics. The disorder is named for Dr. Georges Gilles de la Tourette, the pioneering French neurologist who in 1885 first described the condition in an 86-year-old French noblewoman.
The early symptoms of TS are almost always noticed first in childhood, with the average onset between the ages of 7 and 10 years. TS occurs in people from all ethnic groups; males are affected about three to four times more often than females. It is estimated that 200,000 Americans have the most severe form of TS, and as many as one in 100 exhibit milder and less complex symptoms such as chronic motor or vocal tics or transient tics of childhood. Although TS can be a chronic condition with symptoms lasting a lifetime, most people with the condition experience their worst symptoms in their early teens, with improvement occurring in the late teens and continuing into adulthood.
What are the symptoms?
Tics are classified as either simple or complex. Simple motor tics are sudden, brief, repetitive movements that involve a limited number of muscle groups. Some of the more common simple tics include eye blinking and other vision irregularities, facial grimacing, shoulder shrugging, and head or shoulder jerking. Simple vocalizations might include repetitive throat-clearing, sniffing, or grunting sounds. Complex tics are distinct, coordinated patterns of movements involving several muscle groups. Complex motor tics might include facial grimacing combined with a head twist and a shoulder shrug. Other complex motor tics may actually appear purposeful, including sniffing or touching objects, hopping, jumping, bending, or twisting. Simple vocal tics may include throat-clearing, sniffing/snorting, grunting, or barking. More complex vocal tics include words or phrases. Perhaps the most dramatic and disabling tics include motor movements that result in self-harm such as punching oneself in the face or vocal tics including coprolalia (uttering swear words) or echolalia (repeating the words or phrases of others). Some tics are preceded by an urge or sensation in the affected muscle group, commonly called a premonitory urge. Some with TS will describe a need to complete a tic in a certain way or a certain number of times in order to relieve the urge or decrease the sensation.
Tics are often worse with excitement or anxiety and better during calm, focused activities. Certain physical experiences can trigger or worsen tics, for example tight collars may trigger neck tics, or hearing another person sniff or throat-clear may trigger similar sounds. Tics do not go away during sleep but are often significantly diminished.
What is the course of TS?
Tics come and go over time, varying in type, frequency, location, and severity. The first symptoms usually occur in the head and neck area and may progress to include muscles of the trunk and extremities. Motor tics generally precede the development of vocal tics and simple tics often precede complex tics. Most patients experience peak tic severity before the mid-teen years with improvement for the majority of patients in the late teen years and early adulthood. Approximately 10 percent of those affected have a progressive or disabling course that lasts into adulthood.
Can people with TS control their tics?
Although the symptoms of TS are involuntary, some people can sometimes suppress, camouflage, or otherwise manage their tics in an effort to minimize their impact on functioning. However, people with TS often report a substantial buildup in tension when suppressing their tics to the point where they feel that the tic must be expressed. Tics in response to an environmental trigger can appear to be voluntary or purposeful but are not.
What causes TS?
Although the cause of TS is unknown, current research points to abnormalities in certain brain regions (including the basal ganglia, frontal lobes, and cortex), the circuits that interconnect these regions, and the neurotransmitters (dopamine, serotonin, and norepinephrine) responsible for communication among nerve cells. Given the often complex presentation of TS, the cause of the disorder is likely to be equally complex.
What disorders are associated with TS?
Many with TS experience additional neurobehavioral problems including inattention; hyperactivity and impulsivity (attention deficit hyperactivity disorder—ADHD) and related problems with reading, writing, and arithmetic; and obsessive-compulsive symptoms such as intrusive thoughts/worries and repetitive behaviors. For example, worries about dirt and germs may be associated with repetitive hand-washing, and concerns about bad things happening may be associated with ritualistic behaviors such as counting, repeating, or ordering and arranging. People with TS have also reported problems with depression or anxiety disorders, as well as other difficulties with living, that may or may not be directly related to TS. Given the range of potential complications, people with TS are best served by receiving medical care that provides a comprehensive treatment plan.
How is TS diagnosed?
TS is a diagnosis that doctors make after verifying that the patient has had both motor and vocal tics for at least 1 year. The existence of other neurological or psychiatric conditions[1] can also help doctors arrive at a diagnosis. Common tics are not often misdiagnosed by knowledgeable clinicians. But atypical symptoms or atypical presentation (for example, onset of symptoms in adulthood) may require specific specialty expertise for diagnosis. There are no blood or laboratory tests needed for diagnosis, but neuroimaging studies, such as magnetic resonance imaging (MRI), computerized tomography (CT), and electroencephalogram (EEG) scans, or certain blood tests may be used to rule out other conditions that might be confused with TS.
It is not uncommon for patients to obtain a formal diagnosis of TS only after symptoms have been present for some time. The reasons for this are many. For families and physicians unfamiliar with TS, mild and even moderate tic symptoms may be considered inconsequential, part of a developmental phase, or the result of another condition. For example, parents may think that eye blinking is related to vision problems or that sniffing is related to seasonal allergies. Many patients are self-diagnosed after they, their parents, other relatives, or friends read or hear about TS from others.
[1] These include childhood-onset involuntary movement disorders such as dystonia, or psychiatric disorders characterized by repetitive behaviors/movements (for example, stereotypic behaviors in autism and compulsive behaviors in obsessive-compulsive disorder — OCD).
How is TS treated?
Because tic symptoms do not often cause impairment, the majority of people with TS require no medication for tic suppression. However, effective medications are available for those whose symptoms interfere with functioning. Neuroleptics are the most consistently useful medications for tic suppression; a number are available but some are more effective than others (for example, haloperidol and pimozide). Unfortunately, there is no one medication that is helpful to all people with TS, nor does any medication completely eliminate symptoms. In addition, all medications have side effects. Most neuroleptic side effects can be managed by initiating treatment slowly and reducing the dose when side effects occur. The most common side effects of neuroleptics include sedation, weight gain, and cognitive dulling. Neurological side effects such as tremor, dystonic reactions (twisting movements or postures), parkinsonian-like symptoms, and other dyskinetic (involuntary) movements are less common and are readily managed with dose reduction. Discontinuing neuroleptics after long-term use must be done slowly to avoid rebound increases in tics and withdrawal dyskinesias. One form of withdrawal dyskinesia called tardive dykinesia is a movement disorder distinct from TS that may result from the chronic use of neuroleptics. The risk of this side effect can be reduced by using lower doses of neuroleptics for shorter periods of time.
Other medications may also be useful for reducing tic severity, but most have not been as extensively studied or shown to be as consistently useful as neuroleptics. Additional medications with demonstrated efficacy include alpha-adrenergic agonists such as clonidine and guanfacine. These medications are used primarily for hypertension but are also used in the treatment of tics. The most common side effect from these medications that precludes their use is sedation.
Effective medications are also available to treat some of the associated neurobehavioral disorders that can occur in patients with TS. Recent research shows that stimulant medications such as methylphenidate and dextroamphetamine can lessen ADHD symptoms in people with TS without causing tics to become more severe. However, the product labeling for stimulants currently contraindicates the use of these drugs in children with tics/TS and those with a family history of tics. Scientists hope that future studies will include a thorough discussion of the risks and benefits of stimulants in those with TS or a family history of TS and will clarify this issue. For obsessive-compulsive symptoms that significantly disrupt daily functioning, the serotonin reuptake inhibitors (clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline) have been proven effective in some patients.
Psychotherapy may also be helpful. Although psychological problems do not cause TS, such problems may result from TS. Psychotherapy can help the person with TS better cope with the disorder and deal with the secondary social and emotional problems that sometimes occur. More recently, specific behavioral treatments that include awareness training and competing response training, such as voluntarily moving in response to a premonitory urge, have shown effectiveness in small controlled trials. Larger and more definitive NIH-funded studies are underway.
Is TS inherited?
Evidence from twin and family studies suggests that TS is an inherited disorder. Although early family studies suggested an autosomal dominant mode of inheritance (an autosomal dominant disorder is one in which only one copy of the defective gene, inherited from one parent, is necessary to produce the disorder), more recent studies suggest that the pattern of inheritance is much more complex. Although there may be a few genes with substantial effects, it is also possible that many genes with smaller effects and environmental factors may play a role in the development of TS. Genetic studies also suggest that some forms of ADHD and OCD are genetically related to TS, but there is less evidence for a genetic relationship between TS and other neurobehavioral problems that commonly co-occur with TS. It is important for families to understand that genetic predisposition may not necessarily result in full-blown TS; instead, it may express itself as a milder tic disorder or as obsessive-compulsive behaviors. It is also possible that the gene-carrying offspring will not develop any TS symptoms.
The sex of the person also plays an important role in TS gene expression. At-risk males are more likely to have tics and at-risk females are more likely to have obsessive-compulsive symptoms.
People with TS may have genetic risks for other neurobehavioral disorders such as depression or substance abuse. Genetic counseling of individuals with TS should include a full review of all potentially hereditary conditions in the family.
What is the prognosis?
Although there is no cure for TS, the condition in many individuals improves in the late teens and early 20s. As a result, some may actually become symptom-free or no longer need medication for tic suppression. Although the disorder is generally lifelong and chronic, it is not a degenerative condition. Individuals with TS have a normal life expectancy. TS does not impair intelligence. Although tic symptoms tend to decrease with age, it is possible that neurobehavioral disorders such as depression, panic attacks, mood swings, and antisocial behaviors can persist and cause impairment in adult life.
What is the best educational setting for children with TS?
Although students with TS often function well in the regular classroom, ADHD, learning disabilities, obsessive-compulsive symptoms, and frequent tics can greatly interfere with academic performance or social adjustment. After a comprehensive assessment, students should be placed in an educational setting that meets their individual needs. Students may require tutoring, smaller or special classes, and in some cases special schools.
All students with TS need a tolerant and compassionate setting that both encourages them to work to their full potential and is flexible enough to accommodate their special needs. This setting may include a private study area, exams outside the regular classroom, or even oral exams when the child's symptoms interfere with his or her ability to write. Untimed testing reduces stress for students with TS.
What research is being done?
Within the Federal government, the leading supporter of research on TS and other neurological disorders is the National Institute of Neurological Disorders and Stroke (NINDS). The NINDS, a part of the National Institutes of Health (NIH), is responsible for supporting and conducting research on the brain and central nervous system.
NINDS sponsors research on TS both in its laboratories at the NIH and through grants to major medical institutions across the country. The National Institute of Mental Health, the National Center for Research Resources, the National Institute of Child Health and Human Development, the National Institute on Drug Abuse, and the National Institute on Deafness and Other Communication Disorders also support research of relevance to TS. And another component of the Department of Health and Human Services, the Centers for Disease Control and Prevention, funds professional education programs as well as TS research.
Knowledge about TS comes from studies across a number of medical and scientific disciplines, including genetics, neuroimaging, neuropathology, clinical trials (medication and non-medication), epidemiology, neurophysiology, neuroimmunology, and descriptive/diagnostic clinical science.
Genetic studies. Currently, NIH-funded investigators are conducting a variety of large-scale genetic studies. Rapid advances in the technology of gene finding will allow for genome-wide screening approaches in TS, and finding a gene or genes for TS would be a major step toward understanding genetic risk factors. In addition, understanding the genetics of TS genes will strengthen clinical diagnosis, improve genetic counseling, lead to the clarification of pathophysiology, and provide clues for more effective therapies.
Neuroimaging studies. Within the past 5 years, advances in imaging technology and an increase in trained investigators have led to an increasing use of novel and powerful techniques to identify brain regions, circuitry, and neurochemical factors important in TS and related conditions.
Neuropathology. Within the past 5 years, there has been an increase in the number and quality of donated postmortem brains from TS patients available for research purposes. This increase, coupled with advances in neuropathological techniques, has led to initial findings with implications for neuroimaging studies and animal models of TS.
Clinical trials. A number of clinical trials in TS have recently been completed or are currently underway. These include studies of stimulant treatment of ADHD in TS and behavioral treatments for reducing tic severity in children and adults. Smaller trials of novel approaches to treatment such as dopamine agonist and GABAergic medications also show promise.
Epidemiology and clinical science. Careful epidemiological studies now estimate the prevalence of TS to be substantially higher than previously thought with a wider range of clinical severity. Furthermore, clinical studies are providing new findings regarding TS and co-existing conditions. These include subtyping studies of TS and OCD, an examination of the link between ADHD and learning problems in children with TS, a new appreciation of sensory tics, and the role of co-existing disorders in rage attacks. One of the most important and controversial areas of TS science involves the relationship between TS and autoimmune brain injury associated with group A beta-hemolytic streptococcal infections or other infectious processes. There are a number of epidemiological and clinical investigations currently underway in this intriguing area.
"Tourette Syndrome Fact Sheet", NINDS. Publication date April 2005.
NIH Publication No. 05-2163
Prepared by:
Office of Communications and Public Liaison
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient's medical history.
All NINDS-prepared information is in the public domain and may be freely copied. Credit to the NINDS or the NIH is appreciated.
Last updated January 25, 2006
The early symptoms of TS are almost always noticed first in childhood, with the average onset between the ages of 7 and 10 years. TS occurs in people from all ethnic groups; males are affected about three to four times more often than females. It is estimated that 200,000 Americans have the most severe form of TS, and as many as one in 100 exhibit milder and less complex symptoms such as chronic motor or vocal tics or transient tics of childhood. Although TS can be a chronic condition with symptoms lasting a lifetime, most people with the condition experience their worst symptoms in their early teens, with improvement occurring in the late teens and continuing into adulthood.
What are the symptoms?
Tics are classified as either simple or complex. Simple motor tics are sudden, brief, repetitive movements that involve a limited number of muscle groups. Some of the more common simple tics include eye blinking and other vision irregularities, facial grimacing, shoulder shrugging, and head or shoulder jerking. Simple vocalizations might include repetitive throat-clearing, sniffing, or grunting sounds. Complex tics are distinct, coordinated patterns of movements involving several muscle groups. Complex motor tics might include facial grimacing combined with a head twist and a shoulder shrug. Other complex motor tics may actually appear purposeful, including sniffing or touching objects, hopping, jumping, bending, or twisting. Simple vocal tics may include throat-clearing, sniffing/snorting, grunting, or barking. More complex vocal tics include words or phrases. Perhaps the most dramatic and disabling tics include motor movements that result in self-harm such as punching oneself in the face or vocal tics including coprolalia (uttering swear words) or echolalia (repeating the words or phrases of others). Some tics are preceded by an urge or sensation in the affected muscle group, commonly called a premonitory urge. Some with TS will describe a need to complete a tic in a certain way or a certain number of times in order to relieve the urge or decrease the sensation.
Tics are often worse with excitement or anxiety and better during calm, focused activities. Certain physical experiences can trigger or worsen tics, for example tight collars may trigger neck tics, or hearing another person sniff or throat-clear may trigger similar sounds. Tics do not go away during sleep but are often significantly diminished.
What is the course of TS?
Tics come and go over time, varying in type, frequency, location, and severity. The first symptoms usually occur in the head and neck area and may progress to include muscles of the trunk and extremities. Motor tics generally precede the development of vocal tics and simple tics often precede complex tics. Most patients experience peak tic severity before the mid-teen years with improvement for the majority of patients in the late teen years and early adulthood. Approximately 10 percent of those affected have a progressive or disabling course that lasts into adulthood.
Can people with TS control their tics?
Although the symptoms of TS are involuntary, some people can sometimes suppress, camouflage, or otherwise manage their tics in an effort to minimize their impact on functioning. However, people with TS often report a substantial buildup in tension when suppressing their tics to the point where they feel that the tic must be expressed. Tics in response to an environmental trigger can appear to be voluntary or purposeful but are not.
What causes TS?
Although the cause of TS is unknown, current research points to abnormalities in certain brain regions (including the basal ganglia, frontal lobes, and cortex), the circuits that interconnect these regions, and the neurotransmitters (dopamine, serotonin, and norepinephrine) responsible for communication among nerve cells. Given the often complex presentation of TS, the cause of the disorder is likely to be equally complex.
What disorders are associated with TS?
Many with TS experience additional neurobehavioral problems including inattention; hyperactivity and impulsivity (attention deficit hyperactivity disorder—ADHD) and related problems with reading, writing, and arithmetic; and obsessive-compulsive symptoms such as intrusive thoughts/worries and repetitive behaviors. For example, worries about dirt and germs may be associated with repetitive hand-washing, and concerns about bad things happening may be associated with ritualistic behaviors such as counting, repeating, or ordering and arranging. People with TS have also reported problems with depression or anxiety disorders, as well as other difficulties with living, that may or may not be directly related to TS. Given the range of potential complications, people with TS are best served by receiving medical care that provides a comprehensive treatment plan.
How is TS diagnosed?
TS is a diagnosis that doctors make after verifying that the patient has had both motor and vocal tics for at least 1 year. The existence of other neurological or psychiatric conditions[1] can also help doctors arrive at a diagnosis. Common tics are not often misdiagnosed by knowledgeable clinicians. But atypical symptoms or atypical presentation (for example, onset of symptoms in adulthood) may require specific specialty expertise for diagnosis. There are no blood or laboratory tests needed for diagnosis, but neuroimaging studies, such as magnetic resonance imaging (MRI), computerized tomography (CT), and electroencephalogram (EEG) scans, or certain blood tests may be used to rule out other conditions that might be confused with TS.
It is not uncommon for patients to obtain a formal diagnosis of TS only after symptoms have been present for some time. The reasons for this are many. For families and physicians unfamiliar with TS, mild and even moderate tic symptoms may be considered inconsequential, part of a developmental phase, or the result of another condition. For example, parents may think that eye blinking is related to vision problems or that sniffing is related to seasonal allergies. Many patients are self-diagnosed after they, their parents, other relatives, or friends read or hear about TS from others.
[1] These include childhood-onset involuntary movement disorders such as dystonia, or psychiatric disorders characterized by repetitive behaviors/movements (for example, stereotypic behaviors in autism and compulsive behaviors in obsessive-compulsive disorder — OCD).
How is TS treated?
Because tic symptoms do not often cause impairment, the majority of people with TS require no medication for tic suppression. However, effective medications are available for those whose symptoms interfere with functioning. Neuroleptics are the most consistently useful medications for tic suppression; a number are available but some are more effective than others (for example, haloperidol and pimozide). Unfortunately, there is no one medication that is helpful to all people with TS, nor does any medication completely eliminate symptoms. In addition, all medications have side effects. Most neuroleptic side effects can be managed by initiating treatment slowly and reducing the dose when side effects occur. The most common side effects of neuroleptics include sedation, weight gain, and cognitive dulling. Neurological side effects such as tremor, dystonic reactions (twisting movements or postures), parkinsonian-like symptoms, and other dyskinetic (involuntary) movements are less common and are readily managed with dose reduction. Discontinuing neuroleptics after long-term use must be done slowly to avoid rebound increases in tics and withdrawal dyskinesias. One form of withdrawal dyskinesia called tardive dykinesia is a movement disorder distinct from TS that may result from the chronic use of neuroleptics. The risk of this side effect can be reduced by using lower doses of neuroleptics for shorter periods of time.
Other medications may also be useful for reducing tic severity, but most have not been as extensively studied or shown to be as consistently useful as neuroleptics. Additional medications with demonstrated efficacy include alpha-adrenergic agonists such as clonidine and guanfacine. These medications are used primarily for hypertension but are also used in the treatment of tics. The most common side effect from these medications that precludes their use is sedation.
Effective medications are also available to treat some of the associated neurobehavioral disorders that can occur in patients with TS. Recent research shows that stimulant medications such as methylphenidate and dextroamphetamine can lessen ADHD symptoms in people with TS without causing tics to become more severe. However, the product labeling for stimulants currently contraindicates the use of these drugs in children with tics/TS and those with a family history of tics. Scientists hope that future studies will include a thorough discussion of the risks and benefits of stimulants in those with TS or a family history of TS and will clarify this issue. For obsessive-compulsive symptoms that significantly disrupt daily functioning, the serotonin reuptake inhibitors (clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline) have been proven effective in some patients.
Psychotherapy may also be helpful. Although psychological problems do not cause TS, such problems may result from TS. Psychotherapy can help the person with TS better cope with the disorder and deal with the secondary social and emotional problems that sometimes occur. More recently, specific behavioral treatments that include awareness training and competing response training, such as voluntarily moving in response to a premonitory urge, have shown effectiveness in small controlled trials. Larger and more definitive NIH-funded studies are underway.
Is TS inherited?
Evidence from twin and family studies suggests that TS is an inherited disorder. Although early family studies suggested an autosomal dominant mode of inheritance (an autosomal dominant disorder is one in which only one copy of the defective gene, inherited from one parent, is necessary to produce the disorder), more recent studies suggest that the pattern of inheritance is much more complex. Although there may be a few genes with substantial effects, it is also possible that many genes with smaller effects and environmental factors may play a role in the development of TS. Genetic studies also suggest that some forms of ADHD and OCD are genetically related to TS, but there is less evidence for a genetic relationship between TS and other neurobehavioral problems that commonly co-occur with TS. It is important for families to understand that genetic predisposition may not necessarily result in full-blown TS; instead, it may express itself as a milder tic disorder or as obsessive-compulsive behaviors. It is also possible that the gene-carrying offspring will not develop any TS symptoms.
The sex of the person also plays an important role in TS gene expression. At-risk males are more likely to have tics and at-risk females are more likely to have obsessive-compulsive symptoms.
People with TS may have genetic risks for other neurobehavioral disorders such as depression or substance abuse. Genetic counseling of individuals with TS should include a full review of all potentially hereditary conditions in the family.
What is the prognosis?
Although there is no cure for TS, the condition in many individuals improves in the late teens and early 20s. As a result, some may actually become symptom-free or no longer need medication for tic suppression. Although the disorder is generally lifelong and chronic, it is not a degenerative condition. Individuals with TS have a normal life expectancy. TS does not impair intelligence. Although tic symptoms tend to decrease with age, it is possible that neurobehavioral disorders such as depression, panic attacks, mood swings, and antisocial behaviors can persist and cause impairment in adult life.
What is the best educational setting for children with TS?
Although students with TS often function well in the regular classroom, ADHD, learning disabilities, obsessive-compulsive symptoms, and frequent tics can greatly interfere with academic performance or social adjustment. After a comprehensive assessment, students should be placed in an educational setting that meets their individual needs. Students may require tutoring, smaller or special classes, and in some cases special schools.
All students with TS need a tolerant and compassionate setting that both encourages them to work to their full potential and is flexible enough to accommodate their special needs. This setting may include a private study area, exams outside the regular classroom, or even oral exams when the child's symptoms interfere with his or her ability to write. Untimed testing reduces stress for students with TS.
What research is being done?
Within the Federal government, the leading supporter of research on TS and other neurological disorders is the National Institute of Neurological Disorders and Stroke (NINDS). The NINDS, a part of the National Institutes of Health (NIH), is responsible for supporting and conducting research on the brain and central nervous system.
NINDS sponsors research on TS both in its laboratories at the NIH and through grants to major medical institutions across the country. The National Institute of Mental Health, the National Center for Research Resources, the National Institute of Child Health and Human Development, the National Institute on Drug Abuse, and the National Institute on Deafness and Other Communication Disorders also support research of relevance to TS. And another component of the Department of Health and Human Services, the Centers for Disease Control and Prevention, funds professional education programs as well as TS research.
Knowledge about TS comes from studies across a number of medical and scientific disciplines, including genetics, neuroimaging, neuropathology, clinical trials (medication and non-medication), epidemiology, neurophysiology, neuroimmunology, and descriptive/diagnostic clinical science.
Genetic studies. Currently, NIH-funded investigators are conducting a variety of large-scale genetic studies. Rapid advances in the technology of gene finding will allow for genome-wide screening approaches in TS, and finding a gene or genes for TS would be a major step toward understanding genetic risk factors. In addition, understanding the genetics of TS genes will strengthen clinical diagnosis, improve genetic counseling, lead to the clarification of pathophysiology, and provide clues for more effective therapies.
Neuroimaging studies. Within the past 5 years, advances in imaging technology and an increase in trained investigators have led to an increasing use of novel and powerful techniques to identify brain regions, circuitry, and neurochemical factors important in TS and related conditions.
Neuropathology. Within the past 5 years, there has been an increase in the number and quality of donated postmortem brains from TS patients available for research purposes. This increase, coupled with advances in neuropathological techniques, has led to initial findings with implications for neuroimaging studies and animal models of TS.
Clinical trials. A number of clinical trials in TS have recently been completed or are currently underway. These include studies of stimulant treatment of ADHD in TS and behavioral treatments for reducing tic severity in children and adults. Smaller trials of novel approaches to treatment such as dopamine agonist and GABAergic medications also show promise.
Epidemiology and clinical science. Careful epidemiological studies now estimate the prevalence of TS to be substantially higher than previously thought with a wider range of clinical severity. Furthermore, clinical studies are providing new findings regarding TS and co-existing conditions. These include subtyping studies of TS and OCD, an examination of the link between ADHD and learning problems in children with TS, a new appreciation of sensory tics, and the role of co-existing disorders in rage attacks. One of the most important and controversial areas of TS science involves the relationship between TS and autoimmune brain injury associated with group A beta-hemolytic streptococcal infections or other infectious processes. There are a number of epidemiological and clinical investigations currently underway in this intriguing area.
"Tourette Syndrome Fact Sheet", NINDS. Publication date April 2005.
NIH Publication No. 05-2163
Prepared by:
Office of Communications and Public Liaison
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient's medical history.
All NINDS-prepared information is in the public domain and may be freely copied. Credit to the NINDS or the NIH is appreciated.
Last updated January 25, 2006
Tuesday, March 24, 2009
Teaching Friendship Skills
Making and keeping friends is a central part of entering school. Teaching your child prosocial friendship skills is a valuable part of your relationship with your children.
Where do you begin?
A. A few great books have been written on friendship skills. Ones from the American Girls library include: Friends: Making them and keeping them; The Feelings Book, and Stand Up For Yourself and Your Friends. For middle school children and teens Queen Bees and Wanna Bees is a must-read for parents. For parents who wish to coach their teens to health and wellness, The Parent as Coach by Diana Sterling is amazing for parents of teens.
B. Healthy friendship skills begin with confidence and self-respect. Children who have self-esteem are able to be kind, share, and include others in their friendship circles.
C. Knowing your own social style and what is unique about your child is another fine starting point. Emphasizing that everyone is different and we are all special in our own ways enhances acceptance and tolerance among children.
Here are a few, little discussed, tips on helping your children develop their friendship skills.
1. As young as age four you can begin to help your child discover his or her personal style. What kind of child is yours? Help her see that she is bright, funny, articulate, caring or thoughtful. Teach her how to recognize positive social skills in others so she chooses skillful friends who are likely to share her values.
2. In order to help your child see when she is using prosocial friendship skills, comment specifically on what your child does in her friendships that shows she cares.
“When Jose hurt his arm and you offered to sit with when he could not play, that was a kind thing to do.”
“Offering your sister your sweater at the skating rink when she was cold was a thoughtful thing to do.”
3. Teach your child to observe the behavior of others non-judgmentally in a manner that helps her to see how other people behave. Talk with her about how other people respond to that behavior.
4. As your child gets older help her develop the ability to observe the impact of her behavior on others.
5. Giving your children the words and actions to: a. enter into and exit social groups, b. include other people in their group and c. recognize what characteristics your child wants in his or her friends is invaluable.
Talk with your children about what makes a good friend. Write a short story or a book on what one does to show respect, integrity and honesty. If there is a school-mate who criticizes others or mocks others, that is not a friend you wish for your child to choose as a close mate. Draw distinctions between kids who are willing to lift one another up and those who desire to feel powerful by cutting others down.
Here are some sample social skills you might wish to introduce to your children one skill as a time. Role-play with your children, create positive conversations with your children and teach them the importance of learning these skills.
Sample List of Skills
• Accepting "No"
• Accepting Consequences
• Apologizing
• Arguing Respectfully
• Asking a Favor
• Asking Questions
• Being a Good Listener
• Being in a Group Discussion
• Conversational Skills
• Declining an Invitation
• Expressing Empathy
• Following Rules
• Good Sportsmanship
Developing friendship skills can be fun. So practice, play and enjoy with your children. Friendship will follow.
Where do you begin?
A. A few great books have been written on friendship skills. Ones from the American Girls library include: Friends: Making them and keeping them; The Feelings Book, and Stand Up For Yourself and Your Friends. For middle school children and teens Queen Bees and Wanna Bees is a must-read for parents. For parents who wish to coach their teens to health and wellness, The Parent as Coach by Diana Sterling is amazing for parents of teens.
B. Healthy friendship skills begin with confidence and self-respect. Children who have self-esteem are able to be kind, share, and include others in their friendship circles.
C. Knowing your own social style and what is unique about your child is another fine starting point. Emphasizing that everyone is different and we are all special in our own ways enhances acceptance and tolerance among children.
Here are a few, little discussed, tips on helping your children develop their friendship skills.
1. As young as age four you can begin to help your child discover his or her personal style. What kind of child is yours? Help her see that she is bright, funny, articulate, caring or thoughtful. Teach her how to recognize positive social skills in others so she chooses skillful friends who are likely to share her values.
2. In order to help your child see when she is using prosocial friendship skills, comment specifically on what your child does in her friendships that shows she cares.
“When Jose hurt his arm and you offered to sit with when he could not play, that was a kind thing to do.”
“Offering your sister your sweater at the skating rink when she was cold was a thoughtful thing to do.”
3. Teach your child to observe the behavior of others non-judgmentally in a manner that helps her to see how other people behave. Talk with her about how other people respond to that behavior.
4. As your child gets older help her develop the ability to observe the impact of her behavior on others.
5. Giving your children the words and actions to: a. enter into and exit social groups, b. include other people in their group and c. recognize what characteristics your child wants in his or her friends is invaluable.
Talk with your children about what makes a good friend. Write a short story or a book on what one does to show respect, integrity and honesty. If there is a school-mate who criticizes others or mocks others, that is not a friend you wish for your child to choose as a close mate. Draw distinctions between kids who are willing to lift one another up and those who desire to feel powerful by cutting others down.
Here are some sample social skills you might wish to introduce to your children one skill as a time. Role-play with your children, create positive conversations with your children and teach them the importance of learning these skills.
Sample List of Skills
• Accepting "No"
• Accepting Consequences
• Apologizing
• Arguing Respectfully
• Asking a Favor
• Asking Questions
• Being a Good Listener
• Being in a Group Discussion
• Conversational Skills
• Declining an Invitation
• Expressing Empathy
• Following Rules
• Good Sportsmanship
Developing friendship skills can be fun. So practice, play and enjoy with your children. Friendship will follow.
Monday, March 16, 2009
Books For New Dads!
Crash Course for New Dads
Greg Bishop wasn’t your typical boy growing up. With twelve brothers and sisters, he was expected to help out with his siblings, and he had changed plenty of dirty diapers by the time he became a father of four himself. But Greg knew that most expectant and new fathers didn’t have the same confidence in their parenting abilities as he did. So, on Father’s Day 1990, he got four dads and their babies (aka, the veteran dads) in a room with a dozen men who were soon to be daddies (aka, the rookies), and they talked for three hours. The veterans shared their experiences—and their babies—with the rookies, and a great idea was born. Boot Camp for New Dads has been a hit ever since. It has graduated more than 200,000 veterans in 260 communities across 43 states and in the US Navy, Army and Air Force. (To find a location near you, go to http://www.bootcampfornewdads.org/.)
In the process of educating fathers-to-be, Greg has also written many books and articles. His newest book is Crash Course for New Dads: Tools, Checklists & Cheat-Sheets. This amazing book is filled with guy-friendly lists, forms and charts to prepare men for fatherhood. I can’t even begin to tell you all the great information contained in this book, but some of the highlights include:
What You Need for the Hospital
Handling an Emergency Birth
Learning to Care for Your New Baby
Troubleshooter’s Guide to Crying Babies
How to Support a Mom-to-Be
Baby Blues & Postpartum Depression
Getting Your Love Life Back
When You Become Overwhelmed or Close to It
Infant CPR & Choking Basics
Preparing for Your Family’s Future
…and much, much more
Every father-to-be should read this book. (If he can attend a Boot Camp for New Dads program, that’s even better!) Even moms-to-be will benefit from its practical and organized tips and advice for handling the demands of new parenthood. Greg’s books and programs can’t be beat for the quality of information they provide and the reassurance they offer future parents.
Greg and his wife Alison have generously offered a copy of Crash Course for New Dads to one lucky reader of this blog, PLUS a copy of Greg’s book, Hit the Ground Crawling: Lessons from 150,000 New Fathers.
Greg Bishop wasn’t your typical boy growing up. With twelve brothers and sisters, he was expected to help out with his siblings, and he had changed plenty of dirty diapers by the time he became a father of four himself. But Greg knew that most expectant and new fathers didn’t have the same confidence in their parenting abilities as he did. So, on Father’s Day 1990, he got four dads and their babies (aka, the veteran dads) in a room with a dozen men who were soon to be daddies (aka, the rookies), and they talked for three hours. The veterans shared their experiences—and their babies—with the rookies, and a great idea was born. Boot Camp for New Dads has been a hit ever since. It has graduated more than 200,000 veterans in 260 communities across 43 states and in the US Navy, Army and Air Force. (To find a location near you, go to http://www.bootcampfornewdads.org/.)
In the process of educating fathers-to-be, Greg has also written many books and articles. His newest book is Crash Course for New Dads: Tools, Checklists & Cheat-Sheets. This amazing book is filled with guy-friendly lists, forms and charts to prepare men for fatherhood. I can’t even begin to tell you all the great information contained in this book, but some of the highlights include:
What You Need for the Hospital
Handling an Emergency Birth
Learning to Care for Your New Baby
Troubleshooter’s Guide to Crying Babies
How to Support a Mom-to-Be
Baby Blues & Postpartum Depression
Getting Your Love Life Back
When You Become Overwhelmed or Close to It
Infant CPR & Choking Basics
Preparing for Your Family’s Future
…and much, much more
Every father-to-be should read this book. (If he can attend a Boot Camp for New Dads program, that’s even better!) Even moms-to-be will benefit from its practical and organized tips and advice for handling the demands of new parenthood. Greg’s books and programs can’t be beat for the quality of information they provide and the reassurance they offer future parents.
Greg and his wife Alison have generously offered a copy of Crash Course for New Dads to one lucky reader of this blog, PLUS a copy of Greg’s book, Hit the Ground Crawling: Lessons from 150,000 New Fathers.
The Family Coach on Channel 12 LIVE March 24, 2009 Arizona Midday
Tune in to discuss - What is a blended family?
In a blended family, or stepfamily, one or both partners have been married before and one or both spouses has children from another relationship.
Blending is the process of redefining the family unit to include new parents and or new children. New grandparents, step-parents, aunts, uncles etc may also be involved. The processes of blending a family grows it exponentially.
The blending process includes many unanswered questions: Will we like each other? Who will make the rules? Who will enforce the rules? Will we all get along? Who will tuck me in at night? Will my parents still fight... on and on. It will help you and your children to feel safe and secure if you talk, communicate, share and explore the meaning of your new family, in your home and in the other homes involved.
It is your job as newly evolving blended parents to define for your children will be the family playing field. Defining the kind of family you wish to be will be a joint decision for all, even if the children are quite young.
So get ready for a democracy and begin with a mission statement, clarification of your values and family rules agreed on by all.
As expand your family, a few important things to remember are:
* Have a mission, a method and a plan. Talk with your new spouse about the kind of family you hope to be. Your expectations might differ.
* Discuss division of child-care teen-care responsibilities. Are you marrying someone who wants you care for their kids, how much, how, why etc.
* Be your most grown-up self. If you are becoming a blended family be ready to be the calmest, most mature, most patient adult possible because you will get tested and it is your job to stay calm and mature.
* Be patient . Good relationships take time and trust. Be ready to wait things out, be patient and keep circling back in your new relationships to build trust-filled experiences.
* Limit your expectations. Know that you will probably give a lot of time, energy, love and affection that will not be returned immediately. Think of it as making small investments that may one day yield a lot of interest, but don’t expect anything in return for now.
Given the right support, kids should gradually adjust to their new family members. It is your job to communicate openly, meet their needs for security and give them plenty of time to make a successful transition. If the transition remains bumpy for a long-time seek consultation there are many excellent books and clinicians experienced with blended families.
Resources on Amazon.com
Parenting Essentials ~ Dr. Lynne Kenney DVD
Stepcoupling: Creating and Sustaining a Strong Marriage in Today's Blended Family by Susan Wisdom and Jennifer Green
Blended Families: Creating Harmony as You Build a New Home Life by Maxine Marsolini
Smart Stepfamily, The: Seven Steps to a Healthy Family by Ron L. Deal
Parachutes for Parents: 12 New Keys to Raising Children for a Better World by Bobbie Sandoz-Merrill
In a blended family, or stepfamily, one or both partners have been married before and one or both spouses has children from another relationship.
Blending is the process of redefining the family unit to include new parents and or new children. New grandparents, step-parents, aunts, uncles etc may also be involved. The processes of blending a family grows it exponentially.
The blending process includes many unanswered questions: Will we like each other? Who will make the rules? Who will enforce the rules? Will we all get along? Who will tuck me in at night? Will my parents still fight... on and on. It will help you and your children to feel safe and secure if you talk, communicate, share and explore the meaning of your new family, in your home and in the other homes involved.
It is your job as newly evolving blended parents to define for your children will be the family playing field. Defining the kind of family you wish to be will be a joint decision for all, even if the children are quite young.
So get ready for a democracy and begin with a mission statement, clarification of your values and family rules agreed on by all.
As expand your family, a few important things to remember are:
* Have a mission, a method and a plan. Talk with your new spouse about the kind of family you hope to be. Your expectations might differ.
* Discuss division of child-care teen-care responsibilities. Are you marrying someone who wants you care for their kids, how much, how, why etc.
* Be your most grown-up self. If you are becoming a blended family be ready to be the calmest, most mature, most patient adult possible because you will get tested and it is your job to stay calm and mature.
* Be patient . Good relationships take time and trust. Be ready to wait things out, be patient and keep circling back in your new relationships to build trust-filled experiences.
* Limit your expectations. Know that you will probably give a lot of time, energy, love and affection that will not be returned immediately. Think of it as making small investments that may one day yield a lot of interest, but don’t expect anything in return for now.
Given the right support, kids should gradually adjust to their new family members. It is your job to communicate openly, meet their needs for security and give them plenty of time to make a successful transition. If the transition remains bumpy for a long-time seek consultation there are many excellent books and clinicians experienced with blended families.
Resources on Amazon.com
Parenting Essentials ~ Dr. Lynne Kenney DVD
Stepcoupling: Creating and Sustaining a Strong Marriage in Today's Blended Family by Susan Wisdom and Jennifer Green
Blended Families: Creating Harmony as You Build a New Home Life by Maxine Marsolini
Smart Stepfamily, The: Seven Steps to a Healthy Family by Ron L. Deal
Parachutes for Parents: 12 New Keys to Raising Children for a Better World by Bobbie Sandoz-Merrill
Tuesday, March 10, 2009
Parenting High Ability Children: AAGT Parent Institute on March 28, 2009
This one-day, budget friendly conference on parenting high ability children will provide information, reassurance, and new friends for families trying to make sense of it all. People from all over Arizona come to this informative, positive event.
Arizona Association for Gifted and Talented
2009 Parent Institute: Parenting High Ability Children
Who: Parents, Grandparents, & Educators from all over Arizona
What: Seminars on parenting gifted children
Where: Sandra Day O’Connor College of Law at ASU
Date: Saturday, March, 28th, 2009
Time: 9:00 AM – 4:00 PM
Price: $25, pre-registration required. Go to www.aagtparentday.com
See you there.
Arizona Association for Gifted and Talented
2009 Parent Institute: Parenting High Ability Children
Who: Parents, Grandparents, & Educators from all over Arizona
What: Seminars on parenting gifted children
Where: Sandra Day O’Connor College of Law at ASU
Date: Saturday, March, 28th, 2009
Time: 9:00 AM – 4:00 PM
Price: $25, pre-registration required. Go to www.aagtparentday.com
See you there.
Monday, March 9, 2009
Routines And Chores For Kids
Routines, Tasks and Chores Teach Independence and Responsibility
Getting kids to complete tasks of every day living is important to their development.
If each morning you hear yourself saying, "I said, brush your teeth," or "I said, make your bed," consider the value of clear expectations.
Instead of making a battle out of it, consider your approach. Are you clear in what you expect? Have you clarified if the expected action is a personal or family contribution? Do you assert your expectations modeling peace not anger? Are you enhancing family relationships over asserting control?
Teach your children the value of contributions early on by teaching daily routines, tasks and chores. Be clear, be concrete and be consistent.
Teach, model and expect peacefully and calmly, your expectations, posture and tone will guide the outcome.
STEP #1 Identify Daily Routines For Your Children
Helping your children to identify the components of their daily routine is one step toward practicing independence and responsibility.
"We use task lists to keep the children focused on their brief responsibilities each morning," says Diana from Chicago.
Developing independence take 1) Knowing the expectation 2) Having the skills to exhibit the expected behavior and 3) Being recognized for the success in order to increase the likelihood of exhibiting the behavior next time.
Establish a daily task routine. Make play dates, sports and family fun dependent on their accomplishing specific tasks. It's very simple, you give to the family and the family gives back. Make each child a task list and hang them on the bathroom mirror. These are tasks of daily living and do not confer money they are just a part of being a responsible family member.
Write the tasks down.
JAMES, age 9
Get up
Make bed
Get dressed
Put PJs under pillow
Eat breakfast
Clear the table
Brush teeth
Brush hair
Get backpack
Out the door
Place a 4 x 6 task card on the mirror in the bathroom for each child to check off daily.
"The index card helps the children feel some mastery over their daily activities, they don't have to keep checking with me to guide their responsibilities, they know clearly what they are," offers Diana.
STEP #2 Assign Daily and Weekly Chores
Chores are separate from personal tasks (part of a daily routine) as they are done for the good of the community. Chores teach children the value of living in a group, a community, a family.
I look at chores as valued family contributions. When you live in a home where everyone contributes it is a clean, happy well-run home that is enjoyed by all.
Chores are a part of making expected contributions to the household. Children do not earn money for doing what is expected. They are expected to be a productive part of the family, their tasks are a piece of that, just as listening respectfully and being kind are expected.
Susan from Milwaukee offers this advice, "At our house, the kids are expected to help the “family community” for which they do not get paid money. Just as I make their breakfast or dinner and do their laundry, they have ways in which they contribute to the community. Making their bed, wiping the sink after they brush their teeth, setting the dinner table, and clearing their plates from the table are typical every day expectations."
Jane from Scottsdale agrees. "We have “chores” listed on our fridge, the kids do some each day and some weekly. If we have a big project or something outside the chore list we need done we might offer $2-$5 for that extra activity mostly to support the children's piggy banks.
"On Saturday there is a pretty good chance that our preschool and school-age children will help out, as they can earn valuable spending money for their participation. This money goes to things they care about like horseback riding, going to the water park and having movie night at home. Without hard work there are no horses and there are no trips to the mall, that's just the way it is," Jane says confidently.
STEP #3 Model Your Values
If you are going to give allowance for everyday household tasks, make sure you establish a specific amount, be consistent in giving it out each week and make sure the children complete the tasks assigned to earn allowance.
It is important to also suggest that children do not need to "consume" everything they like. Children can enjoy things in a store and leave them in a store. Life is not about accumulating stuff it's about caring for people.
Kim from Boston offers some clear advice, "When we go to the store, I do not agree to buy the kids small toys or objects that they can purchase with their allowance. We have a ten dollar per week maximum of allowance earned=2 0and they can use that to buy the newest Polly Pocket or Lego toy."
"Further, they are encouraged to put one dollar in savings and one dollar in our “community jar” to give away at the holidays to families in need. If every child contributes, they often have more than one hundred dollars to give away at the holidays, which teaches them to be compassionate as well as generous. They learn the value of hard work early with a spend, save, and donate system," asserts Kim.
Consider delineating what are expected family contributions in your home. Create a morning and evening task list for each child. Keep it simple with (3-8) discrete tasks. If you wish to help your children learn about money management, develop a chore list, assign fees, and encourage your children to spend, save and give. Teach your children the value of contributing to the family in the early years.
Getting kids to complete tasks of every day living is important to their development.
If each morning you hear yourself saying, "I said, brush your teeth," or "I said, make your bed," consider the value of clear expectations.
Instead of making a battle out of it, consider your approach. Are you clear in what you expect? Have you clarified if the expected action is a personal or family contribution? Do you assert your expectations modeling peace not anger? Are you enhancing family relationships over asserting control?
Teach your children the value of contributions early on by teaching daily routines, tasks and chores. Be clear, be concrete and be consistent.
Teach, model and expect peacefully and calmly, your expectations, posture and tone will guide the outcome.
STEP #1 Identify Daily Routines For Your Children
Helping your children to identify the components of their daily routine is one step toward practicing independence and responsibility.
"We use task lists to keep the children focused on their brief responsibilities each morning," says Diana from Chicago.
Developing independence take 1) Knowing the expectation 2) Having the skills to exhibit the expected behavior and 3) Being recognized for the success in order to increase the likelihood of exhibiting the behavior next time.
Establish a daily task routine. Make play dates, sports and family fun dependent on their accomplishing specific tasks. It's very simple, you give to the family and the family gives back. Make each child a task list and hang them on the bathroom mirror. These are tasks of daily living and do not confer money they are just a part of being a responsible family member.
Write the tasks down.
JAMES, age 9
Get up
Make bed
Get dressed
Put PJs under pillow
Eat breakfast
Clear the table
Brush teeth
Brush hair
Get backpack
Out the door
Place a 4 x 6 task card on the mirror in the bathroom for each child to check off daily.
"The index card helps the children feel some mastery over their daily activities, they don't have to keep checking with me to guide their responsibilities, they know clearly what they are," offers Diana.
STEP #2 Assign Daily and Weekly Chores
Chores are separate from personal tasks (part of a daily routine) as they are done for the good of the community. Chores teach children the value of living in a group, a community, a family.
I look at chores as valued family contributions. When you live in a home where everyone contributes it is a clean, happy well-run home that is enjoyed by all.
Chores are a part of making expected contributions to the household. Children do not earn money for doing what is expected. They are expected to be a productive part of the family, their tasks are a piece of that, just as listening respectfully and being kind are expected.
Susan from Milwaukee offers this advice, "At our house, the kids are expected to help the “family community” for which they do not get paid money. Just as I make their breakfast or dinner and do their laundry, they have ways in which they contribute to the community. Making their bed, wiping the sink after they brush their teeth, setting the dinner table, and clearing their plates from the table are typical every day expectations."
Jane from Scottsdale agrees. "We have “chores” listed on our fridge, the kids do some each day and some weekly. If we have a big project or something outside the chore list we need done we might offer $2-$5 for that extra activity mostly to support the children's piggy banks.
"On Saturday there is a pretty good chance that our preschool and school-age children will help out, as they can earn valuable spending money for their participation. This money goes to things they care about like horseback riding, going to the water park and having movie night at home. Without hard work there are no horses and there are no trips to the mall, that's just the way it is," Jane says confidently.
STEP #3 Model Your Values
If you are going to give allowance for everyday household tasks, make sure you establish a specific amount, be consistent in giving it out each week and make sure the children complete the tasks assigned to earn allowance.
It is important to also suggest that children do not need to "consume" everything they like. Children can enjoy things in a store and leave them in a store. Life is not about accumulating stuff it's about caring for people.
Kim from Boston offers some clear advice, "When we go to the store, I do not agree to buy the kids small toys or objects that they can purchase with their allowance. We have a ten dollar per week maximum of allowance earned=2 0and they can use that to buy the newest Polly Pocket or Lego toy."
"Further, they are encouraged to put one dollar in savings and one dollar in our “community jar” to give away at the holidays to families in need. If every child contributes, they often have more than one hundred dollars to give away at the holidays, which teaches them to be compassionate as well as generous. They learn the value of hard work early with a spend, save, and donate system," asserts Kim.
Consider delineating what are expected family contributions in your home. Create a morning and evening task list for each child. Keep it simple with (3-8) discrete tasks. If you wish to help your children learn about money management, develop a chore list, assign fees, and encourage your children to spend, save and give. Teach your children the value of contributing to the family in the early years.
Friday, March 6, 2009
Spring Project Management
You have probably already started mentally making notes about some of the projects that require warmer weather. Whether we wait until spring because of the necessity of working outside to get things done or because we lack the stamina to complete tasks in the winter, spring projects have long been a tradition. It could be as small as changing out lightbulbs or batteries to as big a project as finishing a basement. Making home improvements, no matter the size, helps to restore both our spirits and our homes. Projects can be a way for a family to spend quality time together on a Saturday morning. They also have the potential to improve the value of your home.
Begin to move your projects from your mind to paper. Not only does this help you remember what needs to be done, but it is also one more step in holding yourself accountable. Print out ListPlanIt.com's Seasonal Project List for Spring and hang it on your refrigerator or tack it up on the family bulletin board. As you think of things that would be good to work on, be sure to list them. Include supplies you might need and the steps to accomplish them. Visit listplanit.com for the lists you need to manage your home thoughtfully www.listplanit.com.
Begin to move your projects from your mind to paper. Not only does this help you remember what needs to be done, but it is also one more step in holding yourself accountable. Print out ListPlanIt.com's Seasonal Project List for Spring and hang it on your refrigerator or tack it up on the family bulletin board. As you think of things that would be good to work on, be sure to list them. Include supplies you might need and the steps to accomplish them. Visit listplanit.com for the lists you need to manage your home thoughtfully www.listplanit.com.
Thursday, March 5, 2009
Monday March 9, 2009 MOM COACHING CALL
Join The Circle of Moms Coaching Calls
March 9-30, 2009
Attend the MONDAY Mom Coaching Call For Free. It only takes One Hour to change your family. March 9, 2009 11 am MT 1 ET 10 PT and learn to help your children to follow your family rules.
To enter the call you dial 712-429-0690 and enter the Participant PIN 884068. You may announce yourself or simply listen in, creating a comfortable learning environment depending on your needs and wishes.
These calls are designed to provide moms of children ages 3-8 strategies to:
Create Your Extraordinary Family.
Communicate your expectations to your children.
Help your children to comply with family expectations.
Provide you with the words and actions to help you raise confident, ethical, caring children.
Teach you strategies to distinguish between skill deficits and willful non-compliance.
Help you use your family values to encourage peaceful interactions at home.
Establish bite-sized expectations so that your children become skillful and accomplished at home and at school.
Hear you there!
March 9-30, 2009
Attend the MONDAY Mom Coaching Call For Free. It only takes One Hour to change your family. March 9, 2009 11 am MT 1 ET 10 PT and learn to help your children to follow your family rules.
To enter the call you dial 712-429-0690 and enter the Participant PIN 884068. You may announce yourself or simply listen in, creating a comfortable learning environment depending on your needs and wishes.
These calls are designed to provide moms of children ages 3-8 strategies to:
Create Your Extraordinary Family.
Communicate your expectations to your children.
Help your children to comply with family expectations.
Provide you with the words and actions to help you raise confident, ethical, caring children.
Teach you strategies to distinguish between skill deficits and willful non-compliance.
Help you use your family values to encourage peaceful interactions at home.
Establish bite-sized expectations so that your children become skillful and accomplished at home and at school.
Hear you there!
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