Topic Overview
What is Tourette's disorder?
Tourette's disorder
is a neurological (brain) condition that usually begins in childhood. It causes
a child to make sounds or words (vocal tics) and body movements (motor tics)
that are beyond his or her control. Tourette's disorder (TD) is also known as
Tourette's syndrome and Gilles de la Tourette syndrome. Not all tics are from
TD. Your child may have tics and not develop TD.
Motor tics
usually begin between ages 2 and 8. Vocal tics can begin as early as age 2, but
they usually start a few years after motor tics. Tics generally are at their
worst about age 12. In most children, tics go away or decrease quite a bit in
the teen years. But tics can continue into adulthood.
The effect
tics have on children varies. Some children have mild tics that have a small
impact on their lives. But even mild or infrequent tics may affect your child's
self-esteem and relationships with friends and family. Severe and frequent tics
may require treatment, including medicine and counseling. Although a child's
tics may seem minor, they may interfere with the child's ability to learn and
can cause embarrassment.
It is important to remember that:
- Tics are not a sign of low intelligence and
do not affect intelligence.
- The severity of your child's tics is
not a good indicator of how well he or she will perform in school or in social
situations.
- How well your child can cope with tics can be helped
by a supportive home, school, and community environment.
What causes Tourette's disorder?
TD is thought to
have a genetic component. This means that having a certain
gene or mix of genes makes a person likely to develop
the condition. The exact gene or genes have not been identified. After
answering a doctor's detailed questions about the family's medical history,
many parents of a child with TD are surprised to learn that other family
members may have also had symptoms of the condition.
Other things
that may increase a person's risk for developing tics or TD include
having:
- A mother who suffered from severe nausea and
vomiting during the first trimester of pregnancy, was under severe stress
during her pregnancy, or drank a lot of coffee, smoked cigarettes, or drank
alcohol during her pregnancy.
- Insufficient oxygen or blood supply
during birth.
- A low birth weight and signs of brain injury or an
enlarged section of the brain.
- A lower birth weight than an
identical twin.
What are the symptoms?
Most children with TD have
unique types and patterns of vocal and motor tics. These tics may:
- Be a slight twitching of the eyes, jerking of
the neck, coughing or throat-clearing, or a series of movements and
sounds.
- Occur in bursts of movement (motor) or sounds (vocal). The
burst may last from several seconds to several minutes. Tics may also occur
more slowly.
- Come and go (wax and wane) over a period of weeks and
months and may also change from one type to another. Your child's tics may get
more severe and occur more often, and then gradually get better. Weeks or
months later, your child may develop a new tic, or an old tic may come back for
a while. If your child's symptoms seem to get worse at times, do not assume
that you (or your child's school) are doing something wrong. Although things
that happen at home and school can have an effect, sometimes tics get worse
even when all is going well.
A common stereotype of people with TD is that they all
have uncontrollable outbursts of cursing or obscene or sexual behavior. These
types of complex tics are not required for a diagnosis of TD. Even though these
types of tics may seem routine for TD from what you see on TV and in movies,
most children and teens with TD do not have these symptoms.
How is Tourette’s disorder diagnosed?
A doctor can
diagnose Tourette's disorder based on your child's medical history and the
kinds of symptoms you and other caregivers have noticed. Children may suppress,
or hold back, their tics while they're in the doctor's office, so it may help
to bring a videotape that shows your child's tics. But a doctor may diagnose TD
even though he or she has not seen a video or personally observed any
tics.
Your doctor will want to know whether tics are causing
school or social problems for your child.
As with many other conditions,
there are no brain tests or blood tests that can prove a person has TD. But in
some cases an
electroencephalogram (EEG), a
CT scan, or blood tests are done to check for other
conditions.
The doctor may also check for
attention deficit hyperactivity disorder (ADHD),
obsessive-compulsive disorder (OCD), or other learning or behavior problems. These conditions may occur along with Tourette's
disorder. Also, your doctor may ask whether you have noticed signs of other
problems for which your child is at increased risk, such as
depression or
anxiety disorders.
How is it treated?
Treatment for Tourette's
disorder focuses on managing tics—helping your child and others cope with the
tics. Most cases of TD are mild and will not require medical treatment.
Educating yourself, your child, and those around your child (such as teachers)
about TD will help your child thrive, as will creating a supportive home and
school environment where tics are accepted and accommodated.
In
some cases, such as when other conditions are present, counseling may be
helpful. If your child's tics affect his or her life significantly, medicines
or habit reversal may be considered. The tics can be decreased, but there is no
cure for TD at this time.
Frequently asked questions
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Learning about Tourette's disorder:
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Being diagnosed:
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Getting treatment:
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Living with Tourette's disorder:
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Symptoms
Symptoms of
Tourette's disorder (TD) include motor
tics (sudden body movements) and vocal tics (sounds
and words) that are not under your child's control.
Motor and vocal tics can occur many times throughout the day. They can be
simple or complex.
- Simple motor tics involve only one muscle
group, while complex motor tics can be a combination of many simple motor tics
or a series of movements that involve more than one muscle
group.
- Simple vocal tics involve simple sounds made by moving air
through the nose or mouth. Complex vocal tics involve words, phrases, and
sentences.
Many children and adults with TD report feeling some urge
or sensation in some part of the body that builds and builds until it is
irresistible. This uncomfortable sensation can only be relieved by performing
(releasing) the tic. This is known as "premonitory urge." Not everyone with TD
is aware of such urges, though. In fact, many children may not even realize
that they are having tics. They can be quite surprised when questioned about a
tic they are having, such as when someone asks, "Why are you blinking so
much?"
The tics are not always obvious. They may come and go over
a period of months, change from one type to another, or disappear for no
apparent reason. Tics tend to decrease or go away completely during sleep. Your
child may suppress tics (much like suppressing a sneeze) or not have any for
short periods, such as during a doctor visit, while absorbed in physical
activity, or when concentrating on another activity. Sometimes tics last longer
and are more severe than usual, such as after your child has tried to resist
(suppress) them. They may also get worse when your child is ill, under stress,
or excited.
Be aware that not all tics are related to TD; your
child may have tics and not develop TD.
A common stereotype of
people with TD is that they all have uncontrollable outbursts of cursing or
obscene or sexual behavior. These types of complex tics are not required for a
diagnosis of TD. Even though these types of tics may seem routine for TD from
what you see on TV and in movies, most children and teens with TD do not have
these symptoms.
Other
myths about Tourette's disorder include a belief that
the child can control tics if he or she wants to or that people with TD are
trying to get attention.
Children with TD often have
other disorders and problems, such as
depression,
attention deficit hyperactivity disorder (ADHD), or
obsessive-compulsive disorder (OCD). For more
information, see the following topics:
-
Depression in Children and Teens
-
Attention Deficit Hyperactivity Disorder (ADHD)
-
Obsessive-Compulsive Disorder (OCD)
Common patterns of Tourette's disorder
The tics of
TD vary in
type, severity, and how often they occur. A child may
develop a new tic that seems to increase in frequency and severity over a
period of weeks, and then it gradually tapers off or disappears. Weeks or
months later, a new tic may start, or an old tic may come back and then occur
more and more often and get more severe. This pattern of an increase in tics
followed by a period of fewer symptoms and some periods when tics rarely occur
is known as "waxing and waning" cycles and is typical of TD.
If
your child's symptoms get worse, don't assume that you (or teachers) are doing
something wrong. Although certain
triggers at home or school can make tics worse,
sometimes tics increase and become more severe for no apparent reason.
Although specific tics can come and go unpredictably, Tourette's disorder
often follows a general pattern.
- Uncontrolled movements (motor tics) usually
begin between ages 2 and 8. Uncontrolled sounds and words (vocal tics) can
begin as early as age 2 but usually develop a few years after motor tics. The
first tics are usually simple motor tics affecting the head and neck. But
sometimes vocal tics appear before motor tics. Your child may or may not be
aware of the tics, and you might ignore them because tics are easy to confuse
with symptoms of a cold or allergies. At first, many parents mistake tics such
as frequent blinking or winking with vision difficulties or playful behavior.
- Over the next few years the tics may change in location and become
more severe and/or frequent at times. Your child probably will become aware of
them and may explain them in different ways. Some ways may be comforting: "I
have a silly little cough." Other ways can be upsetting: "I am going crazy," or
"Something inside me is making me act goofy." Your child may try to cover up
the tics by making other sounds or movements. The tics may appear to be normal
activity (such as brushing hair away from the face) except that the activity is
done repeatedly.
- Tics usually are most severe about age 12. Your
child may be able to tell when a tic is starting (premonitory urge). He or she
may feel muscle tightness, a skin irritation (such as a tickle), or a skin
temperature change. But your child may not "feel" a tic coming on or only feel
it sometimes.
- In adolescence, tics happen much less often or
disappear for no reason for up to two-thirds of all children with TD.1 By adulthood, many people with TD still have tics, but they
occur less often and are less severe than in childhood. Adults may continue to
have
other disorders and problems such as ADHD or OCD.
Although the majority of children and teens with TD will
have fewer tics after age 12, some will see an increase during the teen years,
and the symptoms of other conditions (such as
ADHD and
OCD) may not decrease. For many youths, the tics of TD
are not as much of a problem as interference from ADHD, OCD, mood disorders, or
other conditions.
Tics that begin after age 18 are not considered
TD but another
tic disorder.
Exams and Tests
A doctor can diagnose
Tourette's disorder (TD) based on your child's
medical history and the kinds of
tics and other symptoms you and other caregivers have
noticed. As with many other conditions, testing to look at brain function or
substances in blood may be done but can't be used to confirm a diagnosis of TD.
Children may suppress their tics while they are in the doctor's
office, so it may help to bring a videotape that shows your child's tics. But
doctors may diagnose TD even though they have not seen a video or observed any
tics during the child's office visit.
Your doctor will ask you and
sometimes other people who have regular contact with your child questions about
school and other areas of your child's life. You, your child, or the doctor can
also use assessment tools, such as the Yale Global Tic Severity Scale or the
Tourette's Disorder Scale, to help the doctor get a better sense of how your
child is doing.
Tourette's disorder may be diagnosed using the
following criteria:2
- Tics begin before the age of 18 years. Tics
that begin after age 18 are not considered to be caused by Tourette's
disorder.
- Both body movements (motor tics) and sounds or words
(vocal tics) are present (although not always at the same time) and have lasted
for at least 1 year.
- Tics occur many times a day (usually in
bursts) and nearly every day. Tics never disappear for longer than 3 months.
- Tics are not caused by another condition, such as
seizures, or by medicines.
Tourette's disorder can be difficult to diagnose, because
other tic disorders can cause motor movements and/or
vocal sounds. Tests that may be done to check for other conditions
include:
- An
EEG or a
CT scan of the head to see whether your child has
seizures or other brain problems.
- Blood tests to check for other
conditions, including overuse of certain medicines (such as amphetamines);
pediatric autoimmune neuropsychiatric disorders associated with streptococcal
infections (PANDAS), which can affect tic development; or rare
medical conditions, such as not being able to break down copper in the body
(Wilson's disease).
The doctor may also look for signs of other conditions that may occur along with Tourette's disorder. These include attention deficit hyperactivity disorder, obsessive-compulsive disorder, other learning or behavior problems, and depression. For
more information, see the following topics:
-
Attention Deficit Hyperactivity Disorder (ADHD)
-
Obsessive-Compulsive Disorder (OCD)
-
Depression in Children and Teens
Treatment Overview
Treatment for
Tourette's disorder (TD) focuses on managing
tics—helping your child and others cope with the tics.
Most cases of Tourette's disorder are mild and will not need medical treatment.
Educating yourself, your child, and people who have regular contact with your
child (such as teachers) about Tourette's disorder will help your child thrive.
Creating a supportive home and school environment where tics are accepted and
accommodated is also important.
-
Growth and development: Helping your child build self-esteem
In some cases, such as when other conditions are present,
counseling may be helpful. If your child's tics affect his or her life
significantly,
medicines or behavior therapies such as
habit reversal may be considered. The tics can be decreased, but there is no
cure for Tourette's disorder at this time.
Finding the right
treatment for Tourette's disorder can be time-consuming, especially if
other disorders and problems such as
attention deficit hyperactivity disorder (ADHD) are
present. The Tourette's disorder organizations listed in the Other Places to
Get Help section of this topic often can refer you to health professionals who
understand Tourette's disorder and the treatment available.
If
Tourette's disorder occurs along with other disorders or problems, work with
your child and doctor to find out which symptoms are causing the most
difficulties. Get input from teachers to give you a sense of what is happening
in your child's school environment. (Your child's symptoms may be quite
different in school than at home.)
Targeting specific problems is
important so you know which to treat first. Some medicines that are used to
treat tics may not help with any other condition.
Sometimes tics
can be reduced by first treating conditions that can occur along with TD. This
is because some conditions, such as behavioral problems, can make tics worse.
Conditions such as
depression or
anxiety usually need to be treated before TD.
For more information on conditions that often occur with Tourette's
disorder, see the following topics:
-
Attention Deficit Hyperactivity Disorder (ADHD)
-
Obsessive-Compulsive Disorder (OCD)
-
Depression in Children and Teens
Because everyone who has Tourette's disorder has unique
tics and considerations, treatment must be tailored to fit the child.
- Children with mild tics may only need extra support and changes
made to their environment to avoid
triggering tics. Often tics will improve from making a
few changes at school, such as allowing your child to take tests untimed and in
a private room. It may also help to take steps to reduce problems that your
child has as a result of the tics, such as being embarrassed about having tics
when around other kids. For example, you may be able to talk with teachers
about showing a video to your child's classmates about Tourette's disorder.
- Children whose tics seriously affect their quality of life or
ability to function in school, at home, and in the community may benefit from
medicine or therapy to control their tics.
Both you and your child should work with your child's
doctor to manage Tourette's disorder. It is important that decision making is
shared as much as possible. Talk to a doctor about finding help for you and
your child together and individually.
As your child grows and goes
through different developmental stages, you will likely need to provide more
information about TD to encourage his or her understanding and good management
of the condition. Over time, you will also need to see whether adjustments are
needed in your child's school environment. Counseling may also be more
important for your child in some stages of development than others.
Initial treatment
Initial treatment for children
with
Tourette's disorder may include:
-
Educating yourself and others.
Understanding Tourette's disorder makes it possible to
recognize what your child is going through and to help others understand as
well. Your doctor will often start the educational process by talking with you
and your family about Tourette's disorder. The family can then keep learning
about the disorder through the resources that Tourette's disorder organizations
provide. Your doctor, local hospitals, and community outreach programs can help
you. For organizations that can help, see the Other Places to Get Help section
of this topic.
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Understanding how tics affect your child. Try to
identify what
triggers tics. It may help you to find patterns by
writing down when tics occur and what is going on in your child's life during
these times.
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Making changes. Your child may have fewer tics if
you and your child's other caregivers make
changes at home or school, such as alternating house
chores with free time or allowing for rest periods in school.
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Habit reversal. Your child may be able to control
problematic or embarrassing tics through
habit reversal. Habit reversal focuses on creating an awareness of tic
behavior and a response to replace the tic.3 This
technique should be taught by a qualified professional. Ask your doctor for
recommendations.
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Counseling. During counseling sessions, a
qualified therapist helps your child cope with thoughts, feelings, or behaviors
relating to Tourette's disorder. Counseling cannot stop tics, but it may
decrease anxiety and help your child feel better about himself or herself.
Family members may be asked to participate in the counseling sessions.
Ongoing treatment
The symptoms of
Tourette's disorder change as your child gets older.
Tics come and go and seem worse at times. School performance and social
situations that involve talking with or in front of others can be especially
hard for your child. Ongoing treatment consists of matching your management of
the disorder to how the tics are currently affecting your child.
- Understand Tourette's disorder and continue to educate
yourself and others about the disorder.
- Be aware of how tics change
as your child grows. Continue to record the kinds of tics your child develops
and what seems to
trigger them.
- Make
changes at home or school when needed. A solid support
system is important for helping your child to successfully manage
tics.
- Continue counseling, if necessary. If appropriate, continue
to use
habit reversal, which focuses on creating an awareness of tic behavior and
creating a response to replace the tic.
Treatment if the condition gets worse
If
Tourette's disorder is disrupting your child's life,
such as affecting his or her school work or ability to function at home or in
the community, consider:
- Making additional
changes at home or school to accommodate any changes
in how tics occur.
- More extensive counseling for everyone who is
affected by the disorder.
- Using
habit reversal if taught by a well-trained professional. Habit reversal
focuses on creating an awareness of tic behavior and creating a response to
replace the tic.
- Using
medicine. Medicine can help make tics less severe or
occur less often. But some medicines have severe side effects. Talk with
your child's doctor about the benefits and risks of using medicine.
Adult treatment
Because an adult with Tourette's
disorder has had the disease since childhood, treatment generally is well
established and depends on each adult's situation. It is important that those
who interact with the adult who has Tourette's disorder understand the disease
and that tics are not willful. Medicines may be necessary, as is counseling if
Tourette's disorder is severely affecting the adult's life.
Other treatment
Deep brain stimulation (DBS), in
limited studies, has shown promise as treatment for reducing tics in adults. In
this procedure, electrodes are surgically placed in certain areas of the brain,
such as the basal ganglia. These electrodes are connected to another device
that is surgically placed in the chest. The device in the chest sends signals
to the electrodes in the brain. This process can help prevent or limit tics.
Researchers continue to investigate this treatment and the risks of side
effects, such as bleeding in the brain or unwanted changes in motor function.
At this time, DBS is an experimental treatment and is not considered for use in
children.4
Home Treatment
Home treatment for
Tourette's disorder focuses on educating yourself and
others about the condition, understanding how the
tics affect your child, and making changes at home and
school to best accommodate your child.
Write down what kinds of
tics your child has, when they get worse, and the events that happen around
when the tics occur. Keeping such a record can show patterns that may help
identify
triggers, which can help you better manage your
child's symptoms. It may also be useful if your child is starting new
medicines. Be careful not to cause your child more stress by doing this. Don't
approach this in a way that makes your child uncomfortable or more
self-conscious than normal.
Understanding Tourette's disorder makes it possible to recognize and share with others what your
child is going through. Learn as much as you can about the disorder. Your
doctor, local hospitals, school, and community outreach programs can help you. Laws provide for free early intervention services and for equal access to public education for children with Tourette's disorder. Talk with school staff about what is best for your child.
Changes at home and at school
There are many ways
you can help your child with Tourette's disorder at home:
- Don't treat tics as willful behavior.
Although tics can appear to be "on purpose" and may frustrate you, do not
punish your child for having tics, and try not to show any frustration you may
feel. Doing so may increase your child's anxiety and cause more tics. Remember
that your child cannot control his or her tics.
- Alternate household
tasks with free time.
- Notice when your child's tics get worse.
Sometimes you may be able to find triggers and can help your child work through
them or avoid them. But because tics that are associated with Tourette's
disorder come and go, it may be difficult to know exactly why they sometimes
get worse. You can help reassure your child during these times by staying calm
and helping him or her to relax.
- Encourage your child to increase
responsibilities at his or her own pace.
Teachers can help your child with Tourette's disorder at
school if they:
- Provide more time for your child to take
written tests.
- Allow your child to use a computer or recite assignments rather than handwriting them if tics
affect writing.
- Provide a seat where there is little distraction
and some privacy.
- Allow for frequent rest periods when
needed.
- Allow your child to leave the room if he or she needs to
move around or let the tics occur in private.
- Set a good example
for accepting your child. It is important for your child to have teachers who
discourage teasing by responding quickly and firmly whenever it
occurs.
- Provide tutoring, learning laboratories, or special classes
if needed.
Habit reversal
If a well-trained health
professional has worked with you and your child on
habit reversal, continue to practice this with your child. Habit reversal
focuses on creating an awareness of tic behavior and developing a response to
replace the tic.
Other Places To Get Help
Organizations
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National Institute of Neurological Disorders and
Stroke
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| P.O. Box 5801 |
| Bethesda, MD 20824 |
| Phone: |
1-800-352-9424
(301) 496-5751 |
| TDD: |
(301) 468-5981 |
| Web Address: |
www.ninds.nih.gov |
| |
|
The National Institute of Neurological Disorders and
Stroke (NINDS), a part of the National Institutes of Health, is the leading
U.S. federal government agency supporting research on brain and nervous system
disorders. It provides the public with educational materials and information
about these disorders.
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Centers for Disease Control and Prevention (CDC):
National Center on Birth Defects and Developmental Disabilities
(NCBDDD)
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| 1600 Clifton Road |
| Atlanta, GA 30333 |
| Phone: |
1-800-232-4636 (1-800-CDC-INFO) |
| TDD: |
1-888-232-6348 |
| E-mail: |
cdcinfo@cdc.gov |
| Web Address: |
www.cdc.gov/ncbddd |
| |
|
NCBDDD aims to find the cause of and prevent birth
defects and developmental disabilities. This agency works to help people of all
ages with disabilities live to the fullest. The Web site has information on
many topics, including genetics, autism, ADHD, fetal alcohol spectrum
disorders, diabetes and pregnancy, blood disorders, and hearing loss.
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KidsHealth for Parents, Children, and
Teens
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| 10140 Centurion Parkway North |
| Jacksonville, FL 32256 |
| Phone: |
(904) 697-4100 |
| Fax: |
(904) 697-4125 |
| Web Address: |
www.kidshealth.org |
| |
|
This Web site is sponsored by the Nemours Foundation. It
has a wide range of information about children's health, from allergies and
diseases to normal growth and development (birth to adolescence). This Web site
offers separate areas for kids, teens, and parents, each providing
age-appropriate information that the child or parent can understand. You can
sign up to get weekly e-mails about your area of interest.
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Tourette Syndrome Association
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| 42-40 Bell Boulevard |
| Bayside, NY 11361-2820 |
| Phone: |
(718) 224-2999 |
| Fax: |
(718) 279-9596 |
| E-mail: |
ts@tsa-usa.org |
| Web Address: |
www.tsa-usa.org |
| |
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The Tourette Syndrome Association is a volunteer organization whose
mission is to educate the general public and health professionals about
Tourette's disorder (or syndrome). The association also supports research on
Tourette's disorder and provides services to people with Tourette's disorder
and their families. It offers local chapters, publications and films, and a
quarterly newsletter.
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WE MOVE
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| 204 West 84th Street |
| New York, NY 10024 |
| E-mail: |
wemove@wemove.org |
| Web Address: |
www.wemove.org |
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WE MOVE is an Internet resource for movement disorder
information. The organization is dedicated to educating people about the latest
treatment options for neurologic movement disorders. WE MOVE also has
information on support groups and hosts discussions and chat rooms on the Web
site.
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References
Citations
-
Sadock BJ, Sadock VA, eds. (2007). Tic disorders. In
Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th ed., pp. 1235–1243. Philadelphia:
Lippincott Williams and Wilkins.
-
American Psychiatric Association (2000). Tourette's
disorder. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 111–114. Washington, DC: American
Psychiatric Association.
-
Leckman JF (2002). Tourette's syndrome.
Lancet, 360(9345): 1577–1586.
-
Zinner SH (2004). Tourette syndrome—much more than
tics: Management tailored to the entire patient. Contemporary Pediatrics, 21(8): 38–49.
Other Works Consulted
- Fahn S (2005). Gilles de la Tourette syndrome. In LP
Rowland, ed., Merritt's Neurology, 11th ed., chap. 112,
p. 815. Philadelphia: Lippincott Williams and Wilkins.
- Himle MB, et al. (2006). Brief review of habit reversal training for Tourette syndrome. Journal of Child Neurology, 21(8): 719–725.
- Mell LK, et al. (2005). Association between
streptococcal infection and obsessive-compulsive disorder, Tourette's syndrome,
and tic disorder. Pediatrics, 116(1): 56–60.
- Minagar A, et al. (2003). Tourette's syndrome. In RW
Evans, ed., Saunders Manual of Neurologic Practice,
chap. 5, pp. 218–221. Philadelphia: Saunders.
- Murray BJ (2006). Tourette syndrome. In MR Dambro,
ed., Griffith's 5-Minute Clinical Consult, pp.
1132–1133. Philadelphia: Lippincott Williams and Wilkins.
- Pappert EJ, et al. (2003). Objective assessments of
longitudinal outcome in Gilles de la Tourette's syndrome. Neurology, 61(7): 936–940.
- Piacentini JC, Chang SW (2006). Behavioral treatments for tic suppression: Habit reversal training. Advances in Neurology, 99: 227–233.
- Stubbe D (2007). Tourette disorder and other tic disorders. In Child and Adolescent Psychiatry: A Practical Guide, pp. 87–93. Philadelphia: Lippincott Williams and Wilkins.
- Ursano AM, et al. (2008). Tic disorders section
of Disorders usually first diagnosed in infancy, childhood, or adolescence. In
RE Hales et al., eds., American Psychiatric Publishing Textbook of Psychiatry, 5th ed., pp. 898–920. Washington, DC: American
Psychiatric Publishing.
Credits
|
Author
|
Debby Golonka, MPH |
|
Editor
|
Susan Van Houten, RN, BSN, MBA |
|
Associate Editor
|
Denele Ivins |
|
Primary Medical Reviewer
|
Michael J. Sexton, MD - Pediatrics |
|
Specialist Medical Reviewer
|
Karin M. Lindholm, DO - Neurology |
|
Last Updated
|
September 2, 2009 |
