Social Functioning in Tourette Syndrome

Denis G. Sukhodolsky, Ph.D.

Children, adolescents and adults with TS often have difficulties in social functioning that may be associated with tics and with co-occurring conditions such as ADHD or anxiety. Comprehensive clinical services for individuals with TS should include an assessment of strengths and difficulties in social domains along with a careful evaluation of the relative contributions of tics and symptoms of co-occurring disorders.  Furthermore, understanding the strengths, interests, abilities and talents of individuals with TS has become a key principle of treatment planning for children with tics and their families toward the goal of not only reducing symptoms but optimizing adaptive functioning and personal well-being.  The term “social functioning” usually reflects the level of a person’s social skills as well as the development and stability of peer relationships and friendships.  A related concept of “social adjustment” reflects the extent to which children or adults attain socially desirable and developmentally appropriate goals. Social adjustment encompasses the quality of our relationships as perceived by others but also includes self-perceptions of loneliness, social support, or social self-esteem.

Lack of social acceptability, deficits in social self-esteem and difficulty with establishing and maintaining friendships are commonly noted by children with TS and their parents during clinical evaluations. Involuntary movements and vocalizations, particularly the ones that are forceful and complex can be perceived as strange or be disruptive in social interactions. In our clinical experience, many children and families report high levels of support and understanding of tics in schools and communities, a positive trend that is likely due to increasing public awareness of TS. However, it is also common to hear about children being teased about their tics at school or parents and children receiving upsetting comments about tics from the passersby in public places. Middle- school age seems to be the time when children can be particularly at risk of being teased or excluded by their peers because of noticeable tics. In the long run, this may contribute to the lack of opportunities to develop social skills and friendships.  It is also possible that the lack of social skills makes children less capable of communicating with others about their tics, thus creating a vicious circle of peer problems.  It has been observed that tic related impairment is correlated with tic severity and tends to decease with age. By adolescence, however, the issues of awareness of tics in social situations and social self-esteem become more prominent and may lead to avoidance of certain social situations.

The presence of a stable friendship with another child can moderate the negative effects of social exclusion. Children with friends are less likely to show the deleterious consequences of problems with peers in school in comparison to children who do not have close friends. For instance, studies show that having a close friend can ameliorate the negative consequences of being victimized by bullies.  Close friendships also buffer children from problems in peer relationships during a transition into a new school, social isolation and development of adjustment problems. Friends are essential confidants and sources of support in good times and bad, and provide benefits to mental health from childhood to old age. Furthermore, part of the protective effects of friendship may be rooted in self-efficacy, the individual’s belief in her or his ability to form high-quality, lasting relationships with others.  In our work with children with TS and their families, we encourage fostering interests and hobbies that would create opportunities for joining clubs and meeting kids with similar interests. Sports, afterschool programs and community centers provide invaluable opportunities for naturalistically occurring friendships.

It is commonly suggested that children with tics may also benefit from informal (e.g., practicing with parents or siblings) or formal social skills training to prepare the child to respond appropriately in a variety of social situation.  Extensive literature on social skills in children with behavioral and neurodevelopmental disorders suggests that this modality of psychosocial intervention may be helpful for addressing social skills deficits in children with TS.  Specific skills that may be targeted for development vary as a function of a child’s age, interests, and specific deficits in social communication. The complexity of the targeted skills can also range from basic nonverbal social responses, such as making eye contact and smiling, to complex repertoires of social behavior in situations, such as going on a first date or a job interview. Social skills training can be provided in a variety of settings, including outpatient mental health clinics and schools. It can be administered individually, in groups, by video-taped modeling, and with the participation of peer tutors. The training involves a therapist or a teacher giving instruction, modeling the skill, practicing the skill through role-plays and providing corrective feedback and reinforcement for appropriate performance in real-life situations.  Current curricula often have a separate emphasis on and instructions for electronic communication, including text messaging, instant messaging, e-mailing and online safety. Children and their parents are also invited to brainstorm and try out new peer groups and extra-curricular activities in which to find sources of potential friends. Rules of social etiquette derived from valid social norms for typically developing adolescents are discussed and practiced in role-playing exercises. Whenever possible, each rule or step of a particular social skill is acted out through a role-play demonstration so that children can understand its meaning better.

In conclusion, approximately 50 percent of children with TS have impairments in social functioning, and co-occurring conditions such as ADHD and anxiety may further exacerbate these social difficulties. Clinical evaluation of children with TS should include a detailed discussion of strengths and weaknesses in social and school functioning. Focusing on personal strengths and building resilience should be at the center of a comprehensive approach to care for children with TS and their families. Oftentimes pharmacological or behavioral interventions aimed at tics can lead to improvement in functioning. More focused interventions such as social skills training can be helpful to address problems in social functioning.