This case study explores Michael’s experience with the REI Custom Program.
Michael is an 11-year-old young man with vocal and motor tics. His vocal tics included grunting and throat-clearing while his motor tics consisted of lip-smacking and picking, neck-rubbing, and finger-bending.
At the beginning of his REI Custom Program, Michael’s tics were present most of time, usually starting just an hour or so after waking in the morning and continuing until bedtime. The degree and intensity of his tics seemed to be related to his anxiety and energy level. If he was tired, he exhibited more tics. Likewise, when he was anxious, his tics were more pronounced.
Aside from his tics, Michael also had difficulty sleeping, both falling asleep and waking at night. Generally it would take him 1 to 2 hours to fall asleep and he would often wake once at night, usually between 3 and 4 am. Most of time he was able to fall back asleep by having a parent lay with him. Other times, approximately 1 or 2 times per week, he would not be able to go back to sleep. Days after this were often times when he his tic behavior was much worse.
Michael also exhibited high levels of anxiety. This was centered around fear of new places, unexpected events, and separation from parents. On a good day he was able to go to school without clinging and displayed only minor trepidation toward new or unexpected situations, such as an unscheduled trip to the store or an event outside his normal routine. His anxiety exhibited itself as clinginess, crying, and tic behavior, most notably vocal tics.
In addition to the tics, anxiety, and sleep issues, Michael also showed classic signs of attention deficit hyperactivity disorder (AD/HD, ADD, ADHD). These symptoms included restlessness, inattention, impulsive behavior, and low frustration tolerance. It is not uncommon for ADHD symptoms and tics to occur at the same time. In fact, many refer to Tourette’s Syndrome (a severe form of tic disorder) as ADHD with tics. In Michael’s case, the tics were very pronounced whereas his ADHD-type symptoms were less significant than is usually the case when tics and ADHD are combined. This was evidenced by the fact that he was not diagnosed with ADHD.
The goal for Michael’s REI Custom Program was to improve his sleep and reduce his tics and anxiety. Additionally, we intended to improve his ADHD symptoms. This was a lot to accomplish with the program, so the key was to prioritize the focus of his program. We decided to focus on his anxiety and sleep first. This is because:
Sleep: Sleep is essential in moderating any of these symptoms, so improving his sleep would likely also improve some of his other symptoms. As well, according to Michael’s intake, his tics were more frequent and intense when he was tired.
Anxiety: Anxiety was a major issue for him in general and also exacerbated his tic behavior. Reducing his anxiety should not only help with the clinginess and crying incidents, but should also help with the tics.
Track #1: Michael began listening to his track at bedtime. The first night he was calmed while the recording played, but he didn’t fall asleep right away. According to his parent’s feedback, he was calm enough that his dad was able to leave room and turn off the light without incident, even though he took a while to fall asleep. This pattern continued for most of his first week. At about day 8 he fell asleep while the recording played and slept through the night.
During this first track Michael exhibited less anxiety over everyday changes, such as going to school or therapy sessions, where he is separated from his mom. His vocal tics were slightly less frequent, while his motor tics remained pretty much the same.
Tracks #2 and #3: These tracks continued to improve his sleep and reduce his anxiety. He was able to consistently fall asleep while the recording played and only woke up two nights. He was able to fall back asleep both nights that he awoke. This was a significant improvement over his historic sleep patterns. His anxiety was better than before the program started, but still manifested as separation anxiety in some situations.
His tic behavior was variable, with some days being better than others. Overall, his vocal tics were less than before the program according to the tracking documents completed by his parents. His motor tics were largely yet unchanged.
Track #4: For most REI Custom Programs there is a significant jump in the stimulation level of Track #4 as we adjust the focus of client’s program. This was the case with Michael. Because he showed improvements in sleep and some changes in anxiety, it was determined that this REI Track would focus more on his tics, particularly the motor tics, which up to this point had only marginally improved.
The first three days went well – his tics, both vocal and motor, decreased significantly in frequency. He had periods during these days when there was no visible tic behavior. Unfortunately on day 4, he began waking up at night again (something he had not done for almost 3 weeks). This trend of improved tic behavior and night-waking continued for the remainder of Track #4 (6 more days).
Track #5: Because of Michael’s change in sleep patterns, we chose to reduce the stimulation level of this track. This was trade-off between his improving tic behavior and his sleep patterns, but it was chosen because good sleep is important not only to functioning well in general but also because his tics often get worse when he is tired. As well, disrupted sleep patterns during the REI Custom Program usually indicate over-stimulation and the best way to counteract this is to reduce the level of the stimulation.
As expected his sleep improved, but also as expected we observed an increase in his motor tics. His vocal tics remained nearly non-existent. His motor tics, though higher than they were toward the end of Track #4, were still below the level that they were at the beginning of the program, so we were encouraged by his overall progress.
Tracks #6 through #8: We continued the dance between uninterrupted sleep and reduced tics during this three-week period. At times his sleep was off (Track #6) while his motor tics abated. And at times his sleep was good but the motor tics increased (Track #7). This was an interesting development because we always felt that good sleep always contributed to fewer tics. The problem was that it appeared that the type of stimulation needed to help with the tic behavior was disrupting his sleep.
By Track #8 we decided to go with the stimulation that would help with the tics and add a track to play at bedtime for sleep. We asked Michael’s parents to play Track #8 (and the rest of his REI Tracks) during the day and a special REI Program Sleep Track at bedtime. After a few days settling into a schedule that worked – they chose to play the Custom REI Track during breakfast – Michael’s sleep returned to where it was after track #3, with him falling asleep with 30 minutes of turning off the light (and turning on the REI Program Sleep Track) and staying asleep most nights.
Based on his parents’ observations, his motor tics remained somewhat variable, but their frequency overall was down from the beginning of the program. Stressful situations, as expected, increased tic activity. Because his anxiety overall was lower than when he began the program, he seemed to be less bothered by situations that used to be stressful for him. There was no observance of vocal tics during Track #8.
Tracks #9 through #12: Michael’s tic behavior was variable but showed steady progress. The vocal tics were essentially absent and there were longer periods of time with few, if any, motor tics. At one point during this period he caught a cold and his tics increased. They reduced again once his cold was over. This demonstrated more overall improvements but also suggested that stress on his system, both physically and psychologically, still had an impact on his tic behavior.
Michael’s anxiety remained low and his sleep was good, with only the occasional bad night’s sleep. Over the last 6 tracks or so he also improved in some of his ADHD symptoms – he seemed less restless and exhibited a greater ability to handle new situations and life’s frustrations.
The end of the 12-Track program: Michael made significant gains in his sleep, anxiety, and tic behavior during the 12-track program, with minor changes in some of his ADHD-type symptoms.
Sleep: Before beginning the REI Custom Program, he often took 1 to 2 hours to fall asleep. He awoke at night several times per week and many times was unable to fall back asleep again. By the 8th day of the Program, his sleep had improved significantly. This made an impact in many ways, including reducing his tics and lowering his anxiety and frustration intolerance.
Anxiety: At the beginning of the Program, Michael’s day was ruled by anxiety. He was clingy with his mother and fearful of new and unexpected situations and events. Within just a few tracks, his anxiety was noticeably lower. He exhibited less clinginess and became more relaxed in general.
Tics: Before REI, Michael’s tics were near-constant and impacted his life significantly. The vocal tics – grunting and throat-clearing – were especially bothersome because they impacted him negatively in social situations. With these gone and the motor tics much reduced, he is now more comfortable interacting with his peers and is receiving less negative peer attention.
ADHD-type symptoms: Even though the focus of Michael’s REI Custom Program was not directed to his ADHD-type symptoms of restlessness, inattention, impulsivity, and frustration intolerance, he did show some improvements in some areas. As his tics decreased, his restlessness also appeared to reduce. This is likely due to the tic behavior appearing as restlessness or fidgeting.
Michael also showed some improvement in frustration tolerance. This coincided with his improved sleep and reduced anxiety, suggesting that this symptom was caused, at least in part, by his poor sleep and high anxiety levels. Likewise, as his sleep, anxiety, and tic behavior improved, so did his attention. There was no observable change in his impulsivity.
Based on his progress it was decided that Michael continue receiving tracks until there was less variability in his tics and anxiety. We also were ready to begin a more direct focus on his attention and impulsivity.