Academic journal article Social Work

Sexual Abuse or Tourette Syndrome?

Academic journal article Social Work

Sexual Abuse or Tourette Syndrome?

Article excerpt

Sexual abuse of children is a common and serious problem in our society (Haugaard & Peppucci, 1989). A wide range of behavioral abnormalities have been linked to sexual and physical abuse, including bed-wetting, soiling, aggressive behaviors, hyperactivity, rituals, conduct disorder, running away from home, suicidal thoughts, phobias, separation anxiety, sleep disorders, compulsive masturbation, inappropriate sexual talk and play, poor concentration, and poor academic performance (Haugaard & Peppucci, 1989). However, DeYoung (1986) cautioned about the dangers of the indiscriminant use of such indicator lists because they describe symptoms seen in children with other stressors and other disorders. All of the above-mentioned symptoms may occur in association with attention deficit hyperactivity disorder (ADHD) and Tourette syndrome (TS) (Comings, 1987, 1990; Comings & Comings, 1987a, 1987b; Eldridge, Sweet, Lake, Ziegler, & Shapiro, 1977; Erenberg, Cruse, & Rothner, 1986; Nee, Caine, Polinsky, Eldridge, & Ebert, 1980; Stefl, 1984). When individuals who interact with children are asked to be alert to such symptoms but are not taught that alternative explanations exist for such behaviors, injustices can occur. Over the past 10 years, Comings (1990) observed more than a dozen cases where inappropriate actions were taken because the social agencies had no knowledge or understanding of TS. The following case convinced the authors that wider awareness of this problem was needed.

Case Report

After hearing a talk about sexual abuse, Dan, a seven-year-old boy, told his teacher that his father often goes after his penis on a "weenie hunt." Because Dan was well known by the teacher to have a short temper, to constantly pull at his crotch, to grab the crotch of other children and adults, to touch the breasts of teachers, and to do other inappropriate things such as display hyperactivity and hide under desks in school, the teacher suspected he was a victim of sexual abuse by his father and contacted the Department of Protective Social Services (DPSS). In reviewing the record it was found that the family had been reported previously. One report was two months earlier when Dan had been reported for grabbing the crotch of the playground monitor. During the investigation of the last incident, Dan, his twin brother, and two older sisters were interviewed. Dan told the workers that his father had a special room in the house where he kept movies that were rented to neighbors and friends. He and his siblings appeared in a film along with other children he did not know. In late February, the DPSS removed the two boys from the home and four days later came back and removed the rest of the children. The parents were not allowed to see or talk to their children. The parents were on welfare and were receiving Aid to Families with Dependent Children and welfare for themselves. The father was accused of sexually molesting his children, of taking pornographic movies of the children for viewing by adults, and of being a major drug trafficker. All support by public agencies was discontinued, the neighbors were informed of the presence of a sexual abuser in their neighborhood, and his wife was encouraged to leave him.

Is this a straightforward case of sexual abuse with appropriate protective action? The family contacted the authors five days before they were to appear in court. They were seen the next day in the clinic with the following history.

Dan was a "very active" child. He would often take his diapers off, play with himself, and run around inside and outside the house with no clothes on. Between two and three years of age he became obsessed with telephones and stole toy phones from other children. One day his mother opened his toy box and found 15 phones in it. He developed throat-clearing noises that were present every day for more than a year. At age three his parents placed him in a preschool, but he was asked to leave because of his aggressive and disruptive behaviors, refusal to listen, extremely short attention span, constant grabbing at his crotch and the crotch of others, and grabbing at the teachers' breasts. Dan reported to his parents that he often heard voices that would tell him to do bad things. He showed many facial-grimacing tics that became worse under stress.

A psychologist suspected that Dan had ADHD and recommended he be treated with methylphenidate hydrochloride (Ritalin). The father was reluctant to permit this treatment because of his own past history of drug abuse.

Dan constantly had his hand in his pants playing with himself, both at home and in public. He continued to grab himself and others in the crotch and run around the house without clothes on, often with an erection. He liked to stand in front of the mirror and look at himself naked. He had frequent temper tantrums and was very destructive of his own toys and those of his siblings. At one point he tore the wallpaper off much of his room.

One day he grabbed his father in the crotch so hard his father said, "Dan, if you don't stop running around without clothes on, putting your hands in your pants, and grabbing other people I am going to go on a 'weenie hunt.'" Although the verbal threat was usually sufficient to get Dan to stop his inappropriate sexual behaviors, his father had occasionally defensively grabbed him in the crotch area, through his clothes. Dan had a rich fantasy life and once told the teacher he had visited the devil's house. His twin brother told the teacher that Dan just made these things up.

On the first day of kindergarten during recess Dan promptly sought out the largest boy in the school and "punched him out." The diversity of aberrant behaviors led the principal to suspect Dan had TS. Arrangements were planned to have the mother of a TS child with similar problems observe him in class, but this never came about.

In October, Dan began to receive treatment with Ritalin three times a day. The father noticed that the frequency with which he was grabbing his crotch and that of others increased significantly after he began to take Ritalin. This led to the event in December when he grabbed the crotch of the playground monitor so hard that the school reported the incident to DPSS. During this investigation the story of the "weenie hunt" was revealed, and the DPSS worker asked the father to discontinue this practice and not to use the threat anymore.

Family History

The two older sisters, ages eight and nine, were asymptomatic and doing well in school and at home. Dan's identical twin brother demonstrated many of Dan's behaviors, but they were less severe.

The father was 45 years old. He stated that as a child he was hyperactive, very impulsive, and had behavioral problems. He had arm and leg motor tics and sniffing vocal tics all his life. Although he had a history of cocaine abuse, he had been off drugs for the past two years. He described himself as an obsessive-compulsive perfectionist. He had been married three times previously and had a 20-year-old daughter by his second marriage. Over his lifetime he had fulfilled the Diagnostic and Statistical Manual of Mental Disorders, Third Edition--Revised (DSM-III-R) (American Psychiatric Association, 1987) criteria for TS, obsessive-compulsive disorder, ADHD, marijuana and cocaine substance abuse, major depressive disorder, and generalized anxiety disorder.

Dan's mother was 31 years old. She had problems with drug abuse until age 21. She was an only child and described her father as having a very short temper and being a wife abuser. Her father sexually abused her when she was nine years old and raped her when she was 15.

Because Dan's father had a back injury, the family had been on welfare for four years. The father collected video films and was two weeks from opening his own store when his children were removed. He emphasized that he wanted to open a family-oriented store with children and family films, specifically excluding pornographic videos; he denied owning any. The neighbors often came by to view the films, and for several months he had been renting out some from his home for a dollar apiece. He stated that the video of his and other children was a composite film he made. The first part contained films of his wife as a child, followed by videos of their children.

Additional history on Dan showed the presence of echolalia (repeating other words), palilalia (repeating his own words), perseveration, touching things with one hand and then the other (even-up), touching things an even number of times, sleep problems (including insomnia, nightmares and terrors, and sleeptalking), stealing, lying, being cruel to animals, attacking his parents, shouting, short temper, coprolalia (compulsive swearing), picking at his skin, head banging, and crib rocking. Dan fulfilled the DSM-111-R criteria for TS and ADHD. The symptoms in Dan and his father are part of the many behaviors associated with TS (Comings, 1990).

Outcome

In attempting to defend this family, the authors drove 120 miles to testify at the father's trial. The lawyer for the DPSS prevented them from testifying. Two years after the children were first removed from the home, the father still had not seen any of his children. The father was fired from his job, was divorced by his wife, lost his house and car, became homeless, and left the state. The maternal grandmother was given custody of the children, and the mother moved in with her to be with her children. Although the DPSS did not accept the diagnosis of TS, Dan was finally referred to another physician for a second opinion. Although the diagnosis of TS was confirmed, this occurred only after the father had left the state.

Discussion

TS was described by Gilles de la Tourette in 1885. Coprolalia, or compulsive swearing, is one of the most publicized symptoms. Unfortunately, many professionals still think this symptom must be present to make a diagnosis, even though in most recent clinical series it was present in fewer than 30 percent of cases (Comings, 1990; Shapiro, Shapiro, Young, & Feinberg, 1988). Some patients have only mental coprolalia. One of the first large studies emphasizing other disinhibited sexual behaviors was by Eldridge et al. (1977). Of 21 selected families, 12 had troublesome sexual and aggressive impulses including private and public exhibitionism and touching their crotch and the sexual areas of others. In a larger series of 50 patients reported by Nee et al. (1980), 32 percent showed inappropriate sexual activity, 58 percent had coprolalia, and 48 percent showed self-destructive behaviors. Comings and Comings (1982) described a male with TS, major depression, and severe exhibitionism. Although his exhibitionism was controlled for six years with haloperidol, when it began to slowly recur he became more severely depressed. Three hours after returning home from a 72-hour holding room in a psychiatric hospital for attempted suicide, he locked himself in his garage and killed himself.

In a series of 247 consecutive TS cases, the authors reported that 27 percent showed sexual touching (usually of themselves in the crotch), and 7.7 percent had significant problems with public exhibitionism (Comings & Comings, 1987b). Bruun (1988) reported that 5 percent of her TS patients older than 16 exhibited public or semipublic exhibitionism. Comings (1990) observed other inappropriate behaviors in some TS patients: compulsive thoughts about sex, significantly heightened sexual drive, compulsive masturbation both at home and in the classroom, copropraxia (constantly giving the finger sign), coprographia (constantly writing dirty words and pictures), fetishism, placing objects in the rectum, cross-dressing, transvestism, and molestation.

TS is a hereditary disorder, and the presence of a parent and a child with TS can sometimes lead to a confusing entanglement of who started what. However, in the authors' experience, the vast majority of cases concern parents being incorrectly accused of molesting their child because the public agencies were unaware of TS, unaware of the occasional disinhibited sexual behaviors in TS, and unaware of any alternative explanation for inappropriate sexual behavior other than being the victim of sexual abuse.

TS is not a rare disorder. In two epidemiologic studies based on physician questionnaires or public announcements, one in 1,000 to one in 1,500 schoolboys were affected (Burd, Kerbeshian, Wikenheiser, & Fisher, 1986; Caine et al., 1988). In an epidemiologic study based on daily onsite monitoring of three school districts, the frequency of TS in schoolboys, using research criteria, was one in 90 (Comings, Himes, & Comings, 1990). For both sexes the ratio was one in 170.

In the authors' experience, treatment with small doses of haloperidol, fluoxetine, clomipramine hydrochloride, or clonidine hydrochloride often totally eliminate inappropriate sexual behaviors. Any child displaying grossly inappropriate sexual behavior or displaying excessive anger, aggression, and temper tantrums in the classroom or elsewhere should be evaluated by a physician thoroughly familiar with TS. This evaluation should include a careful longitudinal history and a pedigree focusing not only on motor and vocal tics, but also the other disorders associated with the TS spectrum of behaviors (Comings, 1990) and a detailed family history. Ignoring TS or ADHD as part of the differential diagnosis has the potential of producing unjust and punitive actions that add to the difficulty of taking care of these children. Otherwise, attempts to do what is best for these children may cause more harm than good.

References

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Bruun, R. D. (1988). The natural history of Tourette's syndrome. In D. J. Cohen, R. D. Bruun, & J. F. Leckman (Eds.), Tourette's syndrome and tic disorders: Clinical understanding and treatment (pp. 21-39). New York: John Wiley & Sons.

Burd, L., Kerbeshian, J., Wikenheiser, M., & Fisher, W. (1986). A prevalence study of Gilles de la Tourette syndrome in North Dakota school-age children. Journal of the American Academy of Child Psychiatry, 25, 552-553.

Caine, E. D., McBride, M. C., Chiverton, P., Bamford, K. A., Rediess, S., & Shiao, J. (1988). Tourette's syndrome in Monroe County school children. Neurology, 38, 472-475.

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Comings, D. E. (1990). Tourette syndrome and human behavior. Duarte, CA: Hope Press.

Comings, D. E., & Comings, B. G. (1982). A case of familial exhibitionism in Tourette's syndrome successfully treated with haloperidol. American Journal of Psychiatry, 139, 913-915.

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Haugaard, J. J., & Peppucci, N. D. (1989). The sexual abuse of children. San Francisco: Jossey-Bass.

Nee, L. E., Caine, E. D., Polinsky, R. J., Eldridge, R., & Ebert, M.H. (1980). Gilles de la Tourette syndrome: Clinical and family study of 50 cases. Annals of Neurology, 7, 41-49.

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David E. Comings, MD, is director of the Department of Medical Genetics, City of Hope Medical Center, Duarte, CA 91010. Brenda G. Comings, PhD, LCSW, is a psychotherapist in private practice. To find physicians in your area familiar with Tourette syndrome, write to the Tourette Syndrome Association, 42-40 Bell Boulevard, Bayside, NY 11361-2857, or call 718-224-2999.

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