Delivering useful definitions and classifications, pediatric neurologist Ana Grijalvo Perez, MD, discusses tic characteristics, scales to assess severity, what's known about genetic influences, and guidance on when and how to initiate care for children bothered by their own repetitive behaviors. She presents a simple flowchart as well as DSM criteria for diagnosis of Tourette's syndrome; describes effective treatments, including CBIT (Comprehensive Behavioral Intervention for Tics), along with therapies to address common comorbidities, such as anxiety; and sheds light on the rapid increase of tics in teenagers seen during the COVID pandemic (“TikTok tics”). Bonus: Watch a touching video of kids with TS sharing about how the condition affects them.
Hi, good afternoon. Um, let me, uh, first welcome everybody. Thanks for joining me today. Now, I'm going to share my screen and get started on, um, on a topic that I love, which is, um, Tourette's. Um, so, as Virginia mentioned, I'm a pediatric movement disorder uh provider. Uh, Tourettes and ticks in general are a topic that you definitely see in your daily practice and it's um definitely a topic that also recently during the times of the pandemic has become uh more prominent, um, and so I want to discuss several aspects of um tick and diagnosis, treatment, and, um, different options for, for therapy as well as uh functional tic disorders. Um, I have nothing to disclose. And, um, and, um, again, I'm going to go first into um the definition of ticks, going over um characteristics, um the uh frequency and other facts of the epidemiology, some useful uh tick scales, um. A bit onto the genetics of um texts which although this topic is quite complex and then uh more into the classification um typical comorbidities associated with text and then outcome and uh also a little bit into the treatments. OK, so as far as the definition of text, uh, um, these are uh definitely uh repetitive, um, uh, intermittent movements or fragment of movements that can be to some degree suppressible, although in, um, in younger children, that's harder. And um they can be classified in um different um uh types and most commonly classified into um motor and vocals, texts, and then uh depending on the symology or the sequence of movements, they can be more simple versus more complex when there's multiple actions or or sequence of sounds. Of and then there's other ways to classify more based on the semiology if they are more like um tensin or tonic versus more dystonic in nature like opening the mouth wide or ologgyric movements. Um and then, uh, next, what I'm gonna do uh is um go more into um the um typical uh manifestations of text and, uh, and, and different types of common. Texts as well as the impact of those texts uh using a great video that is available on the Tourette Syndrome Association, because I feel like the most important thing with tech. I let our patients talk and um and so we're gonna watch a video that is um um entirely uh um produced using uh patients with Tourette's speaking them uh uh speaking them uh about the texts to us. What ticks do you have? What ticks did you have? Did I have in all my years of having rats, or do you know? OK. What kind of ticks do you have? My worst one right now is I go like that a lot. Yeah, I blink a lot too, and then I roll my eyes back. I hum. That's a new tech. I moved my nose and mouth, and I go like this in my hands when I'm nervous. Yeah, I shake. I'm moving my eyes up, it gives me headache, also shaking my head, doing this that's 3, bending down 4, making the vocal tics, like, oh, that's 6. Gonna get the nipple rubbing tick out of the way now. Serious. The cursing so bad. This, this is a this comes out. I don't want it to happen. When I'm eating my home as I eat things, but there's only 9. I get, and I feel so bad that I have to do that. Out loud. Wait, this is my chance to like doing this I. Twirl my head around like this. There's so many and I play with my fingers. Last year, this new chick happened, it was, it was like a fire alarm. It was so loud. What was it? Want me to do it? OK. That was nonstop. Like every second in school. They're getting worse and worse. I'm getting more. I just don't really like it. So when did you first find out you had Tourette's? Well, when I was in 1st grade, probably in December 21st, I think I was about 8, maybe. It started when I was 5. And now I'm 9. And it's hard. I was about 7. How old are you? 15. 8 years. Yeah. That was my first tick. I remember the first day I ever had ticks, I woke up. How to do that The kid told the teacher on me on your first day. On my first day, he told the teacher on me. He thought I was making a funny face at him, and that was just, I went home and I and I had, I was just, my mind was blown. I had no idea what was going on. The first tick that I've ever had was a dull sound. I had to go to a doctor and she explained what it was to me. We were at the zoo, having a great time seeing friends that we haven't seen in ages. Towards the end, some reason I, I kept doing like duck duck duck duck ta da. It was nonstop and then they had to leave early, go to the hospital, see what was wrong, and the doctor said I hadret syndrome. I had no idea what that was. How did you feel when she told you? I was mad. I didn't like it at all. And then 2nd grade, I was doing this, which got me like put in my own separate reading corner. And so it was absolute like physical isolation and confusion and embarrassment. They took you to the emergency room? Yeah. Were you scared? I was kinda Questionable. What is this? I've never done this before. Did you feel like something was wrong with you? Yeah. I don't know. I didn't know what though. The. Well, for me, having it kinda feels like. Um, this kind of itch you need to scratch. It's an urge, like a sneeze or an itch. Like you need to do a certain movements or motion in order for that itch to kind of go away. This is a tick that doesn't look good. And um it feels like there's a mosquito bite and these bumps um are a product of like a year's worth of biting those individual spots. When people see it, I can imagine they'd be like scared. The first time I was, I was asked about this. It's like self-mutilation kind of. The kid thought that I was like contagious or something. I really did feel like I had a disease because and it sort of looks like I have a disease. There's Something that I find uh a bit shameful about about having my hands scarred like this. What happens when you press one of your texts? I really like the urge badly and I kind of have to do it again. You try and stop them when you're in school at all? I don't know how to stop them. When I'm walking, I have to like do that always. And it makes me nervous when I have to do like bang my knees together because I always get bruises from doing. I used to bang my head back like. Like that, and, and it really hurts. Do you ever try and hold back your ticks? Yes. What happens when you try and hold them back? We like, you'll feel when there's an urge to do it, like whatever it is, it's in your stomach then you do this, if it's in your head, you do that it's like annoying. My best friend constantly when he sees me doing this. He'll he'll take my hands a lot and and he'll he'll stop. I'm like, you know, just, it's not even worth it. If you hold it back now, I'm just gonna do it more later. Well, like how people need to breathe. I need to do this, I kind of like that. I was in. OK. I'm, I'm going to stop it there, but um I find this video is super useful because it brings up many, many of the aspects um that uh we all know happened with ticks, first of all, that ticks come in many, many flavors so it's rare to have only a single textemology. And um and then also very often, um, the age of onset for children uh with texts as they um the different children that participate in this video, they show you it's around the beginning of elementary school and often can continue for many years into middle uh school and high school. And then uh. Uh, most importantly, uh, what, uh, what also transpires through all the interviews of all these children is that, um, there can be a sense of urgency and, and, and often these children, they can be brought to the emergency room by parents sometimes in situations that can be like a family vacation or going to the zoo like one of these um children because excitement. Often uh exacerbate ticks and, and there can be also this um um uh sudden uh increases during, uh, during, during trips during uh uh good uh good stress, right? And, and then, um, the finally what um they were just discussing in this, um this part of the video is about um the sensation of an urge, which uh the older the child is, the better they can elaborate. Uh, but that's what makes it takes hard to suppress because that urge is not going anywhere. Um, I'm going to go into the, the next slide because, um, this, this video is quite long, but, uh, what they share in the next part of the, of the video is unfortunately the The bullying and that often these children experience and the different experiences and situations where they were um uh unfortunately accustomed to bullying in their, in their schools, which um breaks my heart, but it still happens so often to these children. OK, let me move into the next slide. Um, OK. So, so going into um take characteristics, uh, as I was already describing is um the fluctuating course with boxing and winning patterns. Uh, often one pattern that I, I typically see in practice is, uh, and it's well described is the beginning of the school year, the change from Um, summer to going back to school, it's a period in the forward. There is usually a rise in texts. Um, there's multiple exacerbating factors, but definitely, uh, uh, association with um anxiety, stress, lack of sleep, and then also the good stress excitement sometimes just the, um, the videos that I received from families about, uh, you know, to show me, um, the, the baseline, um, tick burden that the children have is when they are at home. Watching a movie or playing video games. Um, then, um, other characteristics are that, uh, ticks are uh suppressible to some degree, particularly in older children. And then there's also a component of suggestibility uh which you can uh see in clinic when you uh start asking questions to patients about their ticks. There's often an increase, um, then, um, very, very important is the uh premonitory urge or the sensory phenomena that happens uh with ticks, and it's what makes very hard to suppress ticks. Uh, it's very well described, it's more Um, more commonly, uh, elaborated by older, uh, older children or adults that have persistent tics and, um, uh. Uh, and, and the patients in, um, in, in the video, clearly, uh, they describe it very well as an itch, like you have to sneeze, uh, that is not going away. Uh, it's coocalized with um the region where you experience the tick, being in the, the neck or the face or vocal tics in the throat, and then, uh, it intensifies uh until the tick is performed and then uh it gets transient relief. Um, as far as epidemiology, um, there's no great, uh, unifying data, but, um, there's definitely, um, um, a higher prevalence of ticks per se as compared to, um, to Tourettes. So especially provisional ticks can be quite frequent, uh, with numbers as high as in the 20% range. Um, and then, uh, as far as, um, the prevalence of Tourettes, that's lower, it's believed to be between 0.3 to 0.7, um, of the population. And uh what is way more rare is to have persistent and debilitating Tourettes into adulthood, that's 1 in 1000. Uh, then one fact that uh you've, uh, uh, probably are quite familiar with is that uh they tend to have uh male predominance, 3 to 1. Uh, and especially more common in, um, uh, patient, uh, population, uh, with uh neurodevelopmental disorders such as autism, fragile X, among others. Um, I, um, I already talked about the age advances, more common in the beginning of elementary school, although I've had patients even as young as age 2 or 3. Then as far as how to um how to quantify uh texts. So this is mostly for uh for research purposes, not so much for clinical practice, although, uh, it's, it can be, um, um, can be done, but it's quite time consuming. The most um established uh teseverity scale is the Yale Global tick severity scale. Um, it has um different components, the impairment component and the total tick, um, more based on the um actual characteristics of the ticks, um, and then the quality of life, um, scale. I'm not gonna go a lot into these ones, again, more use for clinical trials than in um clinical practice. Um, into, um, the genetics of texts and Tourettes in general. So it's quite complex. Uh, we know that there's a strong genetic component, uh, because the rate of Tourette's in uh first degree relatives can be several, um, orders of magnitude higher than in the general population and often when you ask families, there's, there's multiple family members that have ticks. Uh, interestingly though, I've, uh, encountered too that sometimes the awareness, the perception of ticks in a family, um, can, uh, can be somewhat limited. I've definitely have families that Um, to me in clinic that they mentioned that nobody in the family has ticks, but I can notice during the interview that one of the parents has actually ticks and, and, and sometimes. It can be hard also to bring on this history because um authentics can be uh transient and or there can be some social stigma, although fortunately less these days. So, so not everything is out there as far as the family history. Um, then, um, there's, uh, uh, what we know as far as the genetics of, of Tourette's is that it is not uh A single, uh, gene like uh Mendelian inheritance, but there's, um, there's a lot of uh genome-wide association studies that are showing some promising results, um, compared to other neuropsychiatric disorders um such as uh schizophrenia or bipolar, there's um less of, um, uh predictable pattern of irritability, um. Um, again, some of those genome-wide association studies have identified multiple genes. I put a couple in there, um, as potential genes associated correlated with Tourettes. Um, there's definitely, this is definitely an area of where more research is needed, um, uh, and definitely more research into, um, genetics. And um prediction of severity or persistence of text, uh we don't have at least to my knowledge, any available um uh commercial uh Tourette's, um, genetic panels, um, definitely an area where more research would be um. Super, super, uh, welcome. Um, a little bit into the classification of texts, which is super simple, um, and sometimes when we see patients, um, uh, you know, we, I, I often see them at the earliest stages, so if it's, um, before uh 12 month chronicity, this is a provisional tic disorder. Um, when it is over a year in persistence, and often it is the case because sometimes, you know, the, the, um, recollection or just kind of, um, um, um, actually, um Uh, uh, realizing that a tick has been present and uh it's very common for families to just get accustomed to something or attribute it to allergies and sometimes the history of ticks is actually way longer than what initially the parents tell you. But, uh, when there's chronicity of over 12 months, we go into chronic tic disorders, which can be purely motor, purely vocal, or most commonly a combination of both. Um, so super simple classification. And then, um, uh, as you probably have noticed a lot of the um images I have in my talk come from the The Tourette syndrome association such as this one, because it has a lot of really great resources for both, uh, parents, teachers, patients, uh, physicians. So based on the DSM-5 criteria, uh, in order to have a diagnosis of Tourette's, you have to have both, uh, multiple motor and at least one or more vocal texts um over the course of one year. Um, not necessarily concurrently, and cause and that often is not the case. Um, and, and then onset has to be before age 18 and not attributable to other, other conditions such as a post infectious or um stroke or mass, for instance. And um and there hasn't been to, there is not, there's not that requirement anymore to have a tick-free. Uh, interval and as you can see here in the criteria, there's nothing um on the definition of Tourettes that talks about severity of prognosis and, um, uh, which is a common um misconception because um in my experience, a lot of families when they um hear the diagnosis of Tourette, they feel like that means that the um tic disorder is worse and that's not the case. It's just based on on duration and uh association between this one vocal plus uh mother takes as well. OK. Um, so one important point uh with uh Tourette's is that um there's a strong uh prevalence of psychiatric comorbid. It is as high as 85%, um, as you can see here. Um, so this is why I really like this um slide, uh, again from the Tourette Syndrome Association that shows you that ticks are just on the tip of the iceberg. There's a lot underneath and sometimes a lot that is um way more important than the ticks per se, right, such as, um, very, very common, the most common associated comorbidity is ADHD or ADD. Uh, and, and very common as well, obsessive compulsive disorder, especially in, uh, in females and especially more around the pre-adolescence, adolescence age, but sometimes I've seen also children which read that have a strong associated OCD even early, as early as age 7 or 8. then anxiety also super common. And then something that is often not talked about as much, but it can be super disruptive, especially in the family dynamics is um um anger management issues or impulsivity or impulse control disorders. So a lot of these children, they uh still get uh like angry like a toddler when they are older and that can affect um a lot of dynamics at school and at home. Also very common as you see here in this slide, to have more than one comorbidity. So this makes often the case for children, especially with uh when there's mood disorders or significant anxiety or OCD makes it important to uh also have a psychiatrist, um. OK, so, um, something that I like to explain to my patients, uh, when I first met them is that, uh, the rule of thirds, which again, I wish we would have better markers to talk about outcome because right now it's still, um, this what I have, um, um, so basically 1/3 of Of, of, of patients, they have resolution 1/3 get better and uh 1/3 of patients with ticks, they tend to um continue the same or worse into adulthood. Um there's a lot of factors that um play a role in this, uh especially management of psychiatric comorbidities, and there's definitely genetic factors as well. Um, and so, so, so this is what makes, uh, you know, uh, addressing this super complicated because tics are multifactorial. Um, Um, now, I'm gonna talk very, very briefly, um, but I, uh, um, I think it's important to talk about this. It's, um, a relatively new phenomenon, although it's been around now for the pandemic has been around for a few years, but it's the concept of a functional tic disorder. Um, so during the COVID-19 pandemic, especially also super early on, we started to see a rapid increase in, uh, tick-like behaviors, um, you know, the phenomenon that, uh, you've all heard about TikTok ticks. Um, so I've definitely seen a number of these ones, uh, as well as an increase in actually, um, just, um, comment. Tic disorders or Tourettes, uh, but, uh, typically a functional tic disorders as compared to a classic, classic, um, Tourettes or ticks, they tend to happen with um sudden onset, uh, way more severity out of the blue and typically in older children like uh the typical situation would be an Uh, high schooler, more common in females that have a very, very sudden onset of complex tics, particularly, and nobody knows the, a specific reason why they tend to be more complex, uh, upper extremity, uh, motor tics with really complex vocal tics associated. Um, and, uh, and when you uh look at these children, they often don't have the Um, the classic urge, uh, associated with, uh, with classic ticks, and then, uh, they typically have higher scores on different parameters of mental health and they respond less to um the classic treatments for, for ticks, including CIT, um. OK, in regards to um treatment of uh of texts, um, so, um, the main driver for treatment of texts is the, the, um the patient because often what I encounter in, in, in many, uh, many, um, in, uh, visits with, with families is high stress. Uh, parents that are really driving the visit and they want their children treated, but a child that is otherwise not bothered by the text. So if the texts are not bothersome, what I do is education to the family. Um, I provide them with letters of accommodation for school if they are necessary for the kid, and depending on the school setting, but I just monitor the texts. Um, but if they, if the texts are bothersome to the patient, that's when I treat them. And ticks can be bothersome in different ways, also depending on the age of the child, uh, and the location of the, of the tick. Uh, ticks, for instance, can be bothersome because of, uh, you know, very physical reasons like um um a cervical tech where a patient is constantly every couple of seconds moving the neck and it's tender or it can be bothersome because of uh social reasons or Or they uh single you out in a class with a loud vocal tech. So it's very important to dig out what's the reason and if there's bullying, advocate for the child, uh, but if they are um clearly bothersome and it's not been like transient, but you know, it's more or less persistent for some time, what I try to do as first line is behavioral therapy. And, and the mainstay of behavioral therapy for, for text uh that has been around for many decades at this point is called CIIT, which stands for Comprehensive Behavioral Intervention for Text. Um, I have a few slides about this that I'm gonna show you in a minute. Um, but, you know, uh, it's CIT is something that is not amenable for every child. Uh, um, again, I will go more into the, um, uh, what is actually, uh, iIt, uh, but, uh. Um, but it's a technique that, uh, it's hard to, um, implement in younger children because there has to be some degree of body awareness and motivation that is hard to, to, um, pass to a 7 or an 8 year old or a 6 year old. So when ticks are bothersome and uh and a child cannot do behavioral therapy. Uh, or, or just because uh the takes are super, super intense and, you know, therapy is going to take some time. I go into medications. Um, the first line are alphadrenergic drugs like quanicine or lonidine. Uh, I really favor quenfaine over lonidine because my experience is less sedating and, and you can play around with the dosing. And you can play also around with the imme immediate release or the standard release in tunic form, which sometimes can be more gentle and can also help a little bit with the impulsivity or the ADHD symptoms. And uh I usually tend to go as high as 1 mg TID um but um there's room to increase it a little higher if needed. And um then, um there's other group of medications that we sometimes use um. Uh, such as anti-epileptics like the pyramid, but definitely we're more sedating, more behavioral side effects as well. And then there is a big class of neuroleptics, um, and among those ones, Abilify in particular, um, uh, is one of my drugs of choice, especially if there is other associated comorbidity. such as OCD or uh intakes with a high severity, I usually get more benefit from Abilify. Um, and then, um, third line, we do have um other there are other options which in general I don't, I don't um use that often but um definitely tetravenazine. Um, and surgery, DBS, which is more of something that we use more in, in, in the adult population in, but, uh, more like a third line. Um, so, let me talk a little bit about CBIT. Um, so, as I mentioned before, it stands for comprehensive Behavioral Intervention for text. Um, so what it does is, uh, first work, so it's, you've probably heard about habit reversal. So it's a little bit different than habit reversal therapy, which was the name given in the past. It's, uh, it's more, it's a more expanded kind of um treatment. What it does is working. You know, first an awareness of the takes and trying to um uh categorize what is the most bothersome thing, what do you want to target first, and then what are um what are triggers or exacerbating factors or just kind of looking. At the environment as well. And then what you do, what the therapist that does with the patient is trying to train the patient in finding a competing response or competing behavior every time they, they feel the urge and trying to find something that um could lead to a good response and something that you can keep up. At least for a minute while you're having the urge. And then in addition, what you have to do is try to also just look at, uh, as I mentioned, at, at your environment and what things could be triggers, what things need to be addressed, cause otherwise trying to modify only the text is not going to work even if you find a good competing response. For instance, if you have a child that has a lot of social anxiety, uh, you know, unless you address that with therapy or sometimes with uh pharmacological options, uh, every time that child is at school, it's gonna have, uh, increase in, in, in, in the text or, or also, you know, the family dynamics, so many factors as you can imagine. Um, OK, so, so sometimes, uh, CBT gets confused with other types of therapy like cognitive behavioral therapy, but that's, that's something that sometimes these children need actually more than CBIT because if they have Significant anxiety or OCD which are targets for CBT, I always recommend families to try that first, um, because they are going to be in a much better place, um, uh, when they try CBIT than just trying CBIT with, without addressing the other factors. OK, and then I already talked about having reversal therapy. So, this slide is not great, so I just, um, it's just to explain to you a little bit of the um basics of CBIT which I already talked a little bit about and by the way, there's a great um um document on the Tourette Syndrome Association that you can. And give to families explaining more uh civit both in English and Spanish and it basically talks about competing response and then how you have to work with the therapist for uh in general it's about 2 months uh of, of, of, of treatment, uh. Um, there's plenty, plenty of evidence, uh, doing, uh, uh, randomized clinical trials that this is effective and, uh, you know, and, and, um, and in some studies, uh, compared to, um, um, just like this one that I mentioned here, so the results are sustained, you know, um, so it's definitely something that I try to offer to families. Um, I have a list of CBAT providers around the Bay Area. Uh, I wish there would be more providers because definitely there's not enough. Um, there's ways to get trained through the Tourette Syndrome Association. And I wanted to just show you a little video of this person that experienced um CBIT himself. Let me see if we still have time. Let me just I'm a writer teacher. I have Tourette's syndrome and I'm excited to talk about my experience with CBI. What led me to try CBI? I've tried many different treatments for my Tourette's, and over the years people suggested there's this, there's this comparative, uh, therapy that people use for all different things and now they're orienting it for Tourette's. It's called CBIT, and I kept trying other things and um my doctor at Mount Sinai, Barbara Coffey, said that they had um a specialist in the office who um who could take me through CBIT. I went in, you know, every week or so. And did this, this treatment, and I really found that it worked. One thing that I uh that I was excited about was a non-medication based treatment, um, something that was really based on just consistent practice, and I found that it was very useful. How CI has changed my life. Since doing CIT, my life has just gotten a lot better. The real change has been Um, the ability to pause when I, um, feel the urge to tick, whereas in the past, I would assume the urge means I have to tick at some point. Now, while it's not always 100% effective, I generally can at least remember you have a technique to use when this comes on. So for instance, the first tick that uh we applied a competing response to with uh Doctor Fried and on Sinai was. Um, this really often painful tick where I'd curl my toes in my shoes, and she showed me how to, um, apply a competing response that would make it impossible to do the tick, unless I moved out of that position. So I raised my heels, my, my toes and. Falls on my feet are flat on the floor. I can't do the tick unless I'm, I give up that position. So with a lot of training, a lot of practice, not always easy, um, I've basically eliminated that tick, and I've used, uh, different competing responses for each of my ticks. One of which is deep breathing and sort of controlled meditative breathing for my vocal tics, which have always been the worst. I still do the vocal tics, but I at least now know that I have tools, like effective tools that I can use to not just reduce the ticks, but to give me a sense of calm in my life and a sense of ownership over what happens in my, in my mind and body and spirit. So overall, So I'm just gonna pause it in there just to have a little bit more time, but, uh, but, you know, this, this video, I, I choose it because often you encounter families that are against, uh, you know, medication and, uh, and, and, and often our medications, especially the neuroleptics, they have a significant risk of side effects even the second generation ones. So definitely on older patients, especially if they are motivated, I think CI is the way to go. And um you can learn those skills you have to practice. I definitely um encourage families to work more with a therapist if possible, rather than online resources. There's online resources for doing CID. I'm gonna share with you in a minute, but definitely, um, the value of working with a knowledgeable therapist is way beyond working online on your own. Um, so I'm going to skip this video cause it's too long. Um, so what to do while uh waiting to send um your patient with text to a specialist being either a psychiatrist or a neurologist or both. Um, so again, um, I think, uh, definitely, um, very, very important to refer to a psychiatrist or at least to start with a behavioral help with a therapist if your patient has significant um comorbidities, uh, especially depression or severe OCD. Um, but, um, you know, if, if, if it's more of a, a, a classic tech. And uh all those needs are addressed already, um, you know, very, very reasonable to start if the ticks are bothersome and the patient is young with a trial of uh guanfacine, especially or clonidine, uh, if, if that's your preference, um. And then I usually try to address the needs at school because unfortunately sometimes I've encountered situations, especially after the pandemic, where children, especially with vocal texts, sometimes they are isolated in a class because, you know, uh even teachers, they think, well, the, the kid is coughing, sniffing, sniffing, you know, it's contagious. and you know, I, I don't want to get patients ostracized because of, of Tourette's, right? Um, and then what I mentioned earlier about uh CBIT options, so you can find uh different providers through the Tourette Syndrome Association. Um, they have thorough information regarding CEED, so I definitely encourage all physicians to send their patients there. Um, and then there's online, uh, resources, uh, such as Stick Hopper, uh, that can be quite useful, especially if you're in a remote, um, uh, rural area without, um, much opportunities for access. And on the Pychology Today website, all therapists also advertise themselves and families can input their um um um uh keywords like um texts or anxiety or different things, so it's quite useful. And then finally, I'm always happy um to see your patients. Um, I, I love children with Tourette's, um, so many uh so many children that do well and families that need our help.
