Clinical Assessment of TSAssessment of TS involves far more than making a diagnosis. Since symptoms may change in severity and character from hour to hour, a thorough understanding of the patient may take a considerable amount of time. As the patient becomes more comfortable with the physician, there will be less likelihood of symptom suppression or inhibition. Aspects of the patient's daily life that may have clinical significance, including both strengths and difficulties, may also become apparent. The nature, severity, frequency, and degree of disruption from the motor and vocal tics need careful assessment, including factors that may have worsened or ameliorated symptom severity. A critical question concerns the degree to which the tics have interfered with the patient's social, familial, and school/work experiences. It is important to explore the presence of attentional and learning disabilities, obsessions and compulsions, mood disorders, sleep difficulties, and sensory hypersensitivities, as well as obtaining a history of school and/or work performance and relationships with family and peers. Information from collateral sources such as family members and teachers can be very informative. Before being given a diagnosis, the patient and family members may have been in turmoil. The patient may have become extremely distressed by his or her experiences and by the often-negative responses evoked by the symptoms. Parents may have scolded, cajoled, ridiculed, or threatened the child to stop the "weird" and apparently deliberately embarrassing behaviour. The emotional sequelae may affect the patient far beyond the period of childhood. During the evaluation of a child, therefore, family issues (including parental guilt) need to be addressed. Relevant factors elicited through careful diagnostic evaluation can be approached through clarification, education, and therapeutic discussion with the child and the family. Careful assessment of cognitive functioning and school achievement is indicated for children who have problems in school. Children with TS who exhibit school performance difficulties often do not have clearly delineated learning disorders. Rather, their problems tend to be in the areas of attentional deployment, perseverance, and their ability to organize themselves and their work (e.g., executive dysfunction). Many have difficulties with penmanship (graphomotor skills) and compulsions that interfere with writing. Determining specific problem areas will help in the recommendation of alternatives (e.g., extended periods of time for tests, computer use, or the emphasis on oral rather than written reports). However, the cognitive abilities of many children with TS are within the normal range of cognitive functioning. The neurological examination should include documentation of neuro-maturational difficulties and other neurological findings. Patients with TS+ may have non-localizing, so called "soft" neurological findings (such as difficulties with fine and gross motor coordination), which may contribute to performance difficulties. The EEG (electroencephalogram) may sometimes be abnormal in TS, but findings are non-specific. Results of MRI or computed tomography of the brain are typically normal. Although some researchers have reported consistent subtle differences in the volume and symmetry of certain sub-cortical brain structures, these do not yet have clinical utility. Thus, unless there are complicating neurological factors, these tests have no role in the clinical evaluation of TS. In cases of suspected PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections), antistreptolysin titers and anti-DNAse B tests may be considered, though this is still a research procedure. In addition to the standard family history (that includes tics, obsessive-compulsive behaviours, attentional problems, and mood disorders), a description of unusual or troublesome behavioural patters (social difficulties, anger control problems, and impulsivity) is essential. If the physician examines a previously diagnosed patient, a complete medication history is essential to determine what medications were used, what the positive and negative responses to the drugs were at what dosage levels, and why the medications may have been discontinued. A patient or a parent may report that a neuroleptic was not useful or that there were unacceptable side effects. A careful history may reveal that the patient improved, but then developed unrecognized akathisia, or that the side effects were dose-related and probably controllable. A potentially useful area of inquiry, though not officially recognized in the research literature, is tactile hypersensitivity. This may be referred to by occupation therapists ad some parents as "tactile defensiveness". Whether this is much more common in TS than in other neurodevelopmental disorders is still uncertain. The patterns are usually more marked in early childhood, may diminish later, and may include extreme sensitivity to seams in socks, tags in new clothing, belts, turtle-necks, certain food textures, or to bare feet, auditory defensiveness, etc. It is important to recognize this as a potential source of oppositional or angry behaviour that is unlikely to respond to the usual behavioural interventions. in this section:
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