Medication Management of Tourette Syndrome and Co-Occurring Conditions

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Here is a pediatric neurologist. 2:00 Yeah, pull the challenges that attended Harvard for her residency or fellowship and classes towards her master’s degree in public health, doctor heard or earned her medical medical degree at the University of Chicago School of Medicine, and completed her residency in pediatrics at the University of Illinois Hope’s Children’s pediatric residency program. 2:24 Doctor heard evaluate Some treats patients with a variety of neurological and neural behavioral concerns, including but not limited to autism, ADHD, Tourette syndrome neuropsychiatric disorders, and epilepsy epilepsy with a particular expertise and interest in epilepsy. 2:44 Doctor Heard is passionate, supporting causes related to pediatric health, especially, and underserved communities. Welcome, doctor Hurd. We look forward to your presentation. 2:57 All right. Hi everybody. Again, and we are here to learn a lot about the medication management of kids, with Tourette syndrome, in its co-occurring conditions. Again, my name is … heard, and let’s go ahead and get started. 3:13 So questions, What are going to be some of the signs and symptoms of Tourette syndrome? 3:18 What are going to be some of the co-occurring conditions of Tourette syndrome? 3:21 How can we manage and treat these patients with Tourette’s plus Syndrome? And how do you decide when to treat Tourette syndrome? So those are going to be the questions that we’re going to discuss today. 3:31 And as we sort of move through the presentation, I wanted to make sure that we had sort of a little bit of a format in regards to the objectives. So here we’ll learn a little bit about the epidemiology of tourettes types of vocal tics, and types of texts in general definitions, characteristics of Tourette’s diagnoses, prognosis, screening, and then management will spend a lot of time on the management, and then we’ll sort of quickly pop into society and culture. 3:59 So going through, when we talk about the epidemiology of direct threat to something that happens in one in five school age kids, but this is about 20% of kids may have ticks at some point in time in their career, or anytime, anytime during their school age years. 4:15 But may not persist, the combination of having both ticks and Tourette syndrome occur in about 1% of the population, so 100 school 8 kids will end up having to read our or texts. 4:27 It is estimated that over 50% have Tourette’s or Text, but Go undiagnosed general, Tourette’s. Oh, that’s all ages, ethnicity, groups, and races. But happens. It affects males a little bit more often than females. So this isn’t a 4 to 1 ratio, so it happens. It affects boys a little bit more so than girls. 4:50 Whatever we talk about takes, a lot of people sort of use the word. But these are some of the definition that goes along with it. We talked about motor tics. These are movements that happened to occur, and it usually sort of start to face. You sort of start to notice that somebody sort of made blink very often have some facial grimacing, maybe some job movements and head bobbing, jerky, and shoulder shrugs In the way that they’re there for it, Since it here, is sort of the way in which they present. They usually sort of start in your face at the proportion of your face, maybe with an eye blinking, eye rolling, maybe some eyebrow raising. And then sort of come down as you come down to your voice box is usually whenever you start to have the sonic or the vocal tics, and this is where I’m noise is produce. Sometimes you sort of remember, whenever we talk about Tourette’s and the media, oftentimes people sort of recognize that there’s …. 5:38 First amount of common. A common occurrence of Tourette’s, oftentimes it’s a small noise that’s not very forceful or purposeful, so it may be a sniffle or a grant, or maybe a clearing of the throat. But it’s not ever that purposeful as the clearing of the throat that I just did. 5:58 It’s more of a aye. 6:00 So those are some of the things that comes along with the vocal tics. 6:04 Sometimes the vocal tics can become complex equal to the motor techs. Motorcades can sort of turn into things that happen in your arms, in your neck. The vocal tics can become a little bit more complex and sort of can lead to the production of words. Chirps whistles grants. Grouse are some of the common ones that many people may experience. 6:26 Going through, after we identify what are the different types of ticks, whether they’re motor or vocal, how do we get these diagnoses that we as physicians oftentimes use? 6:34 So we have transient tick disorder, Cronk text disorder, Tourette syndrome, and so as you can see here, I’ve tried to do what I can to highlight the time and what is present. 6:45 So, here, it’s either going to be a motor, or a vocal tick that lasts for about six months. 6:50 A quiet tic disorders, going to be a motor, or vocal take that last for greater than a year. And then Tourette syndrome is whenever we had at least two motor ticks and of Oakville take that last for over a year. 7:02 It doesn’t make a huge difference. In the type of motor take, just this presence of two and the type of vocal take just the presence of one. But this has to happen for a total of a year. 7:15 As we go through, Tourette syndrome is a hereditary neurodevelopmental disorder that affects children. Hence, pediatric neurologist, like myself usually will will take care of these kids. and then they can go into adulthood. But we’ll talk about that a little bit more when we get to preferences. 7:30 The ticks are sudden uncontrollable, so these involuntary movements, or something that they cannot fully rhythm. It’s very similar to how we breathe and how we blink. Normally. The movements are sudden it happened sort of relatively frequently. 7:46 So again, as we sort of see the motor ticks or two or more, they usually cycle or change at least one vocaltec or phonic tick. And that will, again, we’ll sort of cycle of change. 8:00 It happens to be something that sort of Western way. So there may be times in which you notice that the vocal tics and the motor takes will become very, very apparent and very frequent. That frequency may sort of depend on emotion. So if we are excited or emotional about anything, whether that is a good emotion, anxious and excited about a birthday party or upset about about to be reprimanded, by, you know, sort of a pair of parental figure. You’ll sort of noticed that those ticks may come out a little bit more. 8:30 And that sort of may happen for, you know, maybe for three weeks it, you’ll notice the motor and or vocaltec sort of persistently and then it’ll sort of go away for three months and then it needs that have come away, go away for three seasons and then come away come again for three days. So, that’s the waxing and waning sort of frequency that I’m sort of speaking about. It comes, and just as quickly as it comes with those sudden movements, it’ll go just as suddenly away. 8:55 As I say to the pediatric neurologist, it hasn’t had this onset before the age of 18. Those are the characteristics of Tourette syndrome, is that it has to have those characteristics that usually gives us that, final diagnosis and ticks can happen. These sudden movements can happen for multiple reasons. But generally, it has said not to be caused by a substance or any other medical condition. 9:18 OK, so then what we’re talking about, diagnoses. So genetically, it can be associated with a few genes, and we’ve identified it does have a hereditary component. So we find that about 47% of patients with Tourette syndrome, have a positive family medical history of threats and their family. 9:37 And sometimes, of those 25% of patients that have a positive, family history of Tourette, it happens to be in both parents. 9:48 So of those that have, Tourette’s, 25% of those kids, will end up having both Mom and Dad with that feature of having both a couple of …. 9:57 And a book will take lesson for about a year. 10:02 But there’s no true diagnostic test. You know, when we think about coming to a medical professional, you think about, OK, is there a lab that can sort of give me that diagnosis of Tourette’s? Is there some type of imaging study, but I need to do an MRI do? I need to do a head CT? Is there some type of EEG or sleep study that goes along with that, and the answer is no. Oftentimes I oftentimes we’ll find these intimate this information during the history. 10:27 So as the parent or the person is coming to tell me a lot about the story as to when it began, how long it’s been, what are the tests that they notice? That’s the diagnostic criteria. 10:39 As we move a little bit further and give you some additional unique characteristics that let me know that this is Tourette’s, and at some of the other things, like my opponents, trimmer, Korea is Tanya …, dyskinesia, …, or epilepsy. 10:55 So it’s a couple of things that sort of uniquely that, you know, that this happens to be Tourette’s, which is more of a neural behavioral illness that has some … 11:05 that may require some treatment versus some of these other things that sometimes can lead to another developmental issue or neurologic issue, that have some additional types of management. 11:20 So here’s what I was talking about. These are the unique diagnostic criteria for Tourette. They usually will have an urge and some people may not know what to urge is or urge is what I consider to be something that. Is it a little bit of a tickle right before the movement happens? So I oftentimes will tell my patients, you know, right before you sneeze, there’s plenty feeling. 11:39 What does that funny feeling? That’s the urge to let you know you’re about this nice, it is, Well, is a sudden movement that sort of happens. Usually, it’s sort of preceded by a reason, but that’s sort of funny feeling. 11:50 If you have right before, is the urge to let you know, to sort of protect yourself, having to face and sort of protect others from this. Nice. That’s going to suit. 11:59 those that have an urge, oftentimes can do some of the other things we’ll talk about a little bit later. 12:03 Another unique characteristic or Tourette’s is the suppress ability. 12:07 And just like you can suppress a sneeze, so this is something similar. You can also suppress some of these verbal tics. Regardless it’s going to happen. But it happens. 12:16 Not to be as as loud as obvious, and you can suppress it to where it’s a little bit more subtle vocalizations, many of the things that I just sort of spoke about, from a neurologic perspective, epilepsy, tremors …, …. 12:33 They usually don’t come along with vocalizations. Those are usually movement disorders. That don’t have vocalizations that comes along with it. 12:40 Then usually, the other thing that sort of goes along with Tourette’s syndrome is that it’s present only in the awake state. 12:47 These sudden movements and changes happen whenever you’re in the weak state only. Some of those other movements will happen whenever you’re falling asleep, and, or sleep, especially, epilepsy. 12:58 And then, if I don’t sort of pick this up during the time in, which we are together, and you’re telling me the history, and it happens to be a waiting period, videos are always helpful. So, if this is something that you’re sort of worried about, your loved one, or your trial, then, try to take a video of it, and then bring that to the physician whenever you have the opportunity. And oftentimes, we can tell a lot by just reviewing the video. 13:21 So, Prognosis, for Tourette syndrome, we sort of talked a little bit about this as a pediatric neurologist, the onset in the pediatric age group. It has to be before the age of 18, or to be correct. But usually, the onset is relatively young, busy, as you’re sort of approaching school age, so, between 5 and 7 years of life. 13:39 And usually, the initial to, as I said before, sort of starts in the head in the face, usually, the most common, when RSI blinking sometime it Smith. And people may sort of recognize it as sort of a facial grimace of some sort that may, sort of be the beginning of awareness of the tick, But I blinking an eye rolling, or the more more comments, sort of image yield, initial ticks. 13:59 The peaking frequency is usually as a sort of a reach and approach, the double digits. So usually between 8 and 12 years of life, sort of notice that there’s going to be a peak in the severity and the severity and the frequency at the text. And it can range anywhere from mild to severe. So obviously, the more severe and the more obvious the ticks are, the more likely it is they’re going to be recognized. 14:22 Many times, these improved by late adolescence, so usually the tick freedom may may arise as they’re sort of becoming a teenager, and sort of, as they’re coming out of pediatric care, they sort of may notice that the school way. 14:35 If that happens to be the case, that’s great. But if not, then, you know, sort of, lead into our adult colleagues in neurology to continue to tweak them. 14:44 And then some people, as we all know, continue to have ticks that persist through adulthood. And if the later, the tick sort of initiate, sometimes a sort of can have more severe texts, more refractory text, more difficult to treat ticks, and oftentimes that’s been a really sort of result in some of the additional treatments. And we’ll talk about a little bit later. 15:08 So, as I said, … can range from mild to severe or whatever. I said it’s a severe. This can sort of initiate into self injurious and debilitating behavior. So whenever I talk about self injurious, sometimes I’ve had a couple of kids it sort of move sort of further back. And oftentimes their shoulder movement sorta cause them to have whose is sometimes the flailing of their arms and their limbs. sort of class them to hit other things, thereby causing it, to be self injurious. The debilitating manner of Tourette’s in general is where the management sort of piece comes in, debilitating is sort of anything that happens. They affect their activity of daily living, And we’ll talk about that in a little bit more detail when they get to management. 15:49 So, as I sort of wrote, a little bit closer to getting to a management, it’s many things that we’re sort of looking at to gage the management. is understanding the types of tips that we had, the frequency of the tips that you have, and the severity. And these things will regularly cycle, So, that type me sort of, change from a motor, Take 12 vocaltec, the vocal and or motor take me change. The frequency may be something that uses sort of notice. Maybe in the morning or whenever they’re tired. They tend to happen a little bit more frequently. 16:18 Whenever there’s some sort of bodily stress, that could be emotional stress that could be sort of environmental stress that could be stress caused from illness. 16:28 That could be stress cause from sleep deprivation and sometimes the severity of the tank based on those things and so those external internal factors are the things that sort of make them happen a little bit more frequently during the waxing period. 16:45 So screening for comorbidities. 16:47 So this is where the treatment sort of starts to come in, and oftentimes the things that may sort of affect their ability to function and, and not have any changes in their activities of daily living. So people with Tourette syndrome up and have other mental or behavioral or developmental conditions that may be present prior to the onset of tips. 17:09 And oftentimes, we noticed that about 80% of people are diagnosed with at least one of these additional conditions. So, as I diagnose Tourettes and oftentimes asking in looking for these other conditions. 17:20 So these comorbidities, the most common co-occurring conditions, is ADHD and OCD. one thing that I would like for you to also sort of recognize is that they are oftentimes acronyms. And so the alphabet soup of T S Tourette syndrome sometimes comes with more frequently, ADHD and OCD behaviors. And so those are sort of the cornerstones and which has started to ask questions once I have diagnosed Amtrak and my patients. 17:48 So what does ADHD prompts, concentrating focusing and impulse control? 17:54 What is obsessive compulsive disorders? It is repetitive or unwanted intrusive thoughts and repetitive behaviors. Again, these are the impulse sick repeat, these routines, rituals. And so I’m hoping that you sort of recognize that impulse is sort of a piece of all three of these that makes them have that commonality. 18:13 Other screenings and other comorbidities are behavioral. 18:16 So sometimes oppositional, defiant, socially inappropriate behaviors. 18:20 Impulsivity, again, as mentioned, rage, aggression, anxiety. So generalized anxiety disorder. … and other acronyms that goes along with the alphabet soup attempt can come along with Tourette syndrome. So just a warrior or Worry Wart, somebody that has access this shyness separation anxiety fearfulness. 18:39 Sometimes these kids can also have learning disability in reading, writing, that mathematics, that has nothing to do with their intelligence. Their IQ, maybe appropriate, but sort of, sometimes, may have some learning disabilities that may associate with it. 18:54 Social skill, deficits and social functioning, they may have some difficulty developing social skills, and dealing with family members that may be not age appropriate. 19:05 Sensory processing issues. 19:07 Having some changes with sensitivities to all of the senses, sense of sound touch, taste, smell, And then sometimes they can have trouble falling asleep or staying. 19:20 So, management. So, I just wanted to make sure that we had that history in that background, That foundation about Tourette syndrome before we start talking about the management of Tourette syndrome. So now that we’ve had the diagnosis, or Tourette syndrome and in our heads, we sort of know what the definition, as well as the vocabulary for, that goes along with Tourette syndrome. Just sort of want to talk about what can we do in regards to the management of Tourette syndrome. 19:44 And as we sort of talk about the management, sort of want to mention here that sometimes management is time and time may sort of exist and not doing anything, allowing the wax to sort of trying to wane and just allow time to allow it to go away. 20:00 Outside of that, we do have behavioral therapy. We didn’t have many medication management and in surgical interventions. So here, I’d like to spend a little bit more time and sort of talk about a couple of patients, and sort of, as we sort of go through our Tourettes Clinic. 20:16 So, welcome to tonight’s click. Here, we have a little boy. His name is Edward. Again, he’s a boy because it happens a little bit more frequently and boys. He is now 14 years of age and so at age in which he has been dealing with threats since he was 12. He’s presenting with the increase in his vocal tics, chirping after illness that he had in LA, has been going on, as well as the chirping has been going over the last two weeks. 20:42 And, he fills them a moment prior to the chart. 20:45 And so, here, I just wanted to highlight several things in him It ended up being that the illness sort of provoked the occurrence of these vocal tics and then, he says, he can feel them a moment before the trip had actually, happens with his vocal tics. 21:01 So what should we do next forever? 21:03 So Averitt happens to not necessarily have anything that is wildly bothersome to him. 21:11 The chirp is something that he can know what happens right before it. 21:16 And so in my mind, I would say, for first, do no harm, So watchful waiting is appropriate treatment mechanism for those that sort of have a vocal tick that happens to be simple that happens to not be bothersome. 21:31 So nothing actually happens to be a treatment, and so how do I choose that? 21:36 Oftentimes I’ll choose that based on a few factors and seeing how it that affects them behaviorally. 21:44 And so when do can we use something called habit Russell therapy? 21:49 It’s wherever you are able to identify, urge and remember whatever if he said that he’s able to identify the urge or the sort of a funny tikal right before it happens. 21:58 So he’s able to identify his urge, and so oftentimes will use something called habit reversal Therapy to combat the involuntary movement, which is the tick. And for him, it’s a vocal tick to go along with the voluntary movement. Where he sort of may decide to push his tongue. Profit is now maybe decided curless toes and issues, but she sort of combat a involuntary movement with a voluntary movement, thereby canceling them out or making the take much more subtle. 22:28 So this would be something that I would use for him because he’s of age to, to sort of control it in that way. He is of age to actually have an urge and he’s of age to possibly be somebody that’s involved in habit reversal Therapy. 22:44 So have a Virtual therapy. Here to teach us awareness, he now has the awareness and it creates a competing Volunteer Your Response, whether that’s pushing his tongue or a group of his mouth. Pulling his toes with tinting is abdominal Muscles. 22:55 Have a reversal therapies, A behavioral therapy, that is in the umbrella of Comprehensive behavioral interventions for tips, C B I T. 23:06 So it includes had a reversal therapy. 23:08 That’s what the HR team is, as well as Relax and relaxation training, functional interventions, And so some of these functional interventions is sort of the pushing up of his tongue, which obviously sort of reduces the likelihood of that sort of coming out. 23:23 Relaxation techniques will usually sort of decrease the, the emotional sort of component that comes along with robotics. 23:31 Then just having some awareness of the environmental triggers, whether that’s the nervousness of being around certain friends or certain people, and then usually the … is oftentimes helpful in about eight sessions. So, on average, about 50% had a reduction in their severity and improvement in the function of their lives. That usually lasts about six months after the completion of about eight sessions of CPIC. 23:57 And so oftentimes I’ll try it to start that off first Mainly as a behavioral therapy especially whenever they understand their urge or that you that free feeling of that sort of odd feeling that happens right before one of their takes actually occurs. 24:12 Because, overall, our goal, whenever we’re treating tourettes from a management standpoint, is to reduce the severity and the frequency of the ticks. 24:20 So now let’s go back to Tourette’s Clinic. And now we have a little boy named Peyton. Either 13 year old boy with Tourette’s, And he’s had it, since he’s been seven. 24:29 Now at the age of 13, he’s noticing that maybe ADHD is a little bit more of a concern. He’s doing poorly, academically, and socially. 24:38 So why is this important? Oftentimes, I usually like a treat. 24:43 Treat ADHD and Tourette’s whenever you have to treat Tourette’s whenever it sort of more of a barrier to their activities of daily living. Or if it’s a classical problem with the quality of life. 24:56 And so once we start to have core functionality in your academic days in their social relationships, that’s really whenever I feel like medication management should step in. 25:10 So what should we do next for paint? 25:12 with neural, with Tourette syndrome sort of being a behavioral issue? These behaviors are actually sort of causing him not to lead to his greatest potential. So let’s do something to try to see if we can make paints life a little bit better. 25:25 So medication management is usually often in my life or my patients. Usually whenever it’s affecting their quality of life or their activities of daily living. 25:34 So are they getting bullied because of their ticks? 25:38 They’re getting conduct market school oftentimes happens a little bit more whenever some teachers may not understand or they’re making noises and they feel like those noises are causing them to disrupt class. It’s causing any type of pain or duress, and so that pain and arrest oftentimes happen a little bit more with the more severe motor kicks. Sometimes. It’s a little bit more of the complex ticks. This will cause them to have more movements of their shoulders and arms. 26:04 And so that pain is something that I usually will start medications for, or if it’s part of this function to the patient. And so for Peyton, this is truly true for him. It has caused the dysfunction to him. and so that is the reason that I would try medication management for him. 26:22 So whenever we talk about medication management, we have various reasons that we use various medications, and some that are FDA approved, and some that are not FDA approved. 26:31 So in the pediatric world, we find that many medications are considered to be off label uses versus only uses. So whatever, I sort of talk about that, you can sometimes look for those at Google and go online. 26:43 You can sometimes find, like, various medications that may be used for Tourette’s in the pediatric world. as a whole, regardless of his pediatric neurology or GI or just as a pediatrician, There are many off label uses for medications in the pediatric population that you may not see FDA approved use for the adult population. 27:06 And, a very common set of them are the Alpha agonists. 27:09 Want the same quantity, both of these alpha Agnes agonists are off label uses for Tourette syndrome and tips. 27:18 So, we oftentimes will use these very commonly well known in the pediatric world for Tourette syndrome, and oftentimes I use … quantity. 27:30 Mainly whenever you sort of notice that there is a combination of having Tourette syndrome, as well as ADHD, Tourette syndrome, as well as impulsivity, Tourette syndrome, as well as anxiety, Tourette syndrome, as well as difficulty falling asleep. 27:48 So sort of here, I sort of hit many of the very obvious, very common side effects or comorbidities that come along with Tourette’s. And, using my alpha, Agnes agonists are the ones that I usually start off with. 28:00 Want the scene and quantity, oftentimes can come also as a extended release formulation, that extended release formulation does sort of help with compliance. Again, all of these kids are using young young kids, approaching their teenage years. 28:15 And if we can sort of get them to start on a medication that maybe only at night or once a day, it’s sort of increasing compliance. As we all know, you know, we’re not going to end up improving the issue, unless we’re taking the medicine, and the medicines has to be, something that will reach, we routinely do. 28:33 And so, oftentimes, want the scene and quantity, are my first choice, especially whenever it comes down to ADHD. 28:40 And Tourette, mainly because of the improvement in the, and they are compliant when we give it at night, improvement in their sleep when we give it at night. And possible, reduction of the side effects. 28:53 When we give it at night, want the senior quantity or both well-known for possibly causing sedation. So, it may work in our favor for those that have sleep issues and may also work in our favor whenever it comes down to dealing with the nighttime dosing. 29:09 Oftentimes, I give it a bedtime. And wherever it’s given at that time, it frequently will result and by the time they think week, they are no longer groggy or bothered by being the possible side effects of sedation. 29:23 So, … and clonidine are initially started with the immediate Release Formulations, giving it their time. Monitoring four AM, grogginess or sedation, oftentimes a masculine appearance. If it is more difficult to wake them up, they have to go to the more often, you just sort of moving slower. 29:39 And then I noted adjustment is based on those, that feedback, you start off at a low dose and then can go up to 4 or 5 times that sort of initial goal dose, depending on affect and side effects. 29:54 And then quantity as well, also has a extended release formulation for it, called … Press. And the other name for the same whenever it is, extended release formulation is ted-x. 30:08 And then going down to the FDA approved medications, or the anti-psychotics. Usually I’ll use the anti-psychotics for whenever. There’s a little bit more of the behavioral piece of it. Things that a little bit are more of the OCD behaviors will talk about that with our next next patient. Some of the depression sort of issues, some of the issues that come along with anxiety. 30:32 But I just quickly want to chita remember, some of these names. And we’ll come back to them whenever we sort of talking about our next patient. 30:38 So, first generation and second generation, as we sort of talk about medication management and other sort of general overview. Pharmacology, sort of same point as, first generation is the, the, the original, anti-psychotic, first generation tend to be older, sometimes happens to be more effective, but sometimes comes with a lot more side effects that makes it intolerable. So, oftentimes, the second generation medications are newer happened to have been produced mainly because they reduce many of the side effects that make them intolerable, and oftentimes are much more tolerated by the patient. 31:13 So oftentimes, the second generation medication’s oftentimes much better use and have less side effects that tend to be tolerable. So my sort of goto second generation anti-psychotic, happens to be vilified. 31:28 But overall, whenever we talk about anti-psychotics at all, sometimes they can have some side effects that are irreversible. 31:36 Or sometimes hard to said to deal with one of which is to increase in appetite weight, gain. That sometimes can sort of result in a change in their mood. Whether moods can be a little bit more flat. Sometimes it can result in more sedation and more drowsiness in comparison to the Alpha agonists. And many of those things can sort of result in sometime sort of long term side effects of illness called tardive dyskinesia. 32:06 And so oftentimes, I will use some of the anti-psychotics in hopes of improving there, the Tourette Syndrome and or OCD behavior. But oftentimes trying to make sure that we’re not going to go past to something a little bit more permanent or a little bit more bothersome Mike. But again, it’s difficult to address later. 32:26 So just going to the second line anti-psychotics are those that, just sort of reiterating, here, making them a little bit older because those are the ones that I prefer to use because those second generations tend to have less of those side effects. 32:44 Alright so let’s go back to Tourette’s Clinic. So now we have Giovanni. Giovanni is a 17 year old boy with Tourette syndrome since he’s been eight and he presents with awful, facial tics and this is more of a grim missing that. He sort of recognizes that, prevents them from reading and walking and he also has those behavior. So Giovanni is somebody that oftentimes have a patient premise that causes him to almost week, this, week in, sort of, sometimes frequently happens, on one side of his face. But sometimes it will sort of require that, it happens in both eyes, thereby allowing him to hold on to his eye closure For a long period of time. 33:22 Thereby causing it to be very difficult for him to read and furthermore just walk, just because he can’t see because sometimes the facial tics get stuck. 33:31 So this is very debilitating to Giovanni and sometimes definitely changes his quality of life. 33:37 Furthermore, he has started to develop OCD behaviors where he has these routine rituals that prevent him from getting out of the house. 33:46 In the mornings, frequently, his mom wakes them up very early and recognizes that he’s awake, very early. 33:54 Schools at eight, Giovanni frequently will wake up around or for 30 to begin his washing routine, despite having we’re taking a bath the night before. 34:05 The wake up at 4 30 cleaning entire bathroom, despite having done this before and then have everything in order, clothes are ironed, all of those things. And it has sort of tap things channel mites. 34:20 And so those OCD behavior sort of prevent him from getting one a good night’s sleep to sort of causes him anxiety if the cleaning materials are not available for him. And so all of those things have sort of led to this quality of life that has been bother. 34:37 With that being said, he frequently is late for school. 34:42 So what should we do? Next, Becky? 34:46 So … can be used for patients with Madison cortex. So botulinum toxin is oftentimes known as Botox. And we sort of can’t do this in the office where we will inject them muscle group that happens to be most affected. For him, it happened to be a little bit more on his right than it was on his left. So oftentimes would come to office and he would get the Botox sort of injected into the muscle groups that are most effected. This can be used to be helpful for the cortex and oftentimes will relax those muscles thereby reducing the pupil ticks that are quite bothersome. 35:21 Hoping that this will lead to improvements in his ability to read and write and what sort of function. 35:29 So the … to be the treatment mechanism that we would use for its vocal tapes that we find in his face. 35:37 So, sometimes, we come from medication management and sort of discuss. We can go to something that is a little bit more dramatic or refractory, complex text and sometimes deep brain stimulation is something that is used. This is a surgery when you click an apparatus actually physically in the brain. This is a open cranium surgery that we put an apparatus in the brain that targets the movement centers where these ticks sort of reside. And then with time, it sort of starts to stimulate. 36:08 So it’s a neuromodulator, Laurie, mechanism that is used for refractory complex texts. 36:14 These these types of ticks are the ones that are very difficult to treat, refractory, to medication, refractory, to ease and quality of life. 36:26 Very debilitating and oftentimes will go as far as these types of surgeries that can be helpful. 36:33 Oddly enough, it would also be helpful for those that also have OCD behaviors. So, deep brain stimulation happen to be quite helpful for those that have not only refractory complex text but also OCD behaviors. And we found that it’s been quite helpful for allowing those people to have less debilitating issues with their quality of life. 36:55 Now here is this rubric that I’m hoping that you can see in sort of essentially your brain a little bit, kind of it comes down to medication management. 37:03 And so we sort of talk about starting at the very top. Are there any comorbidities like ADHD, OCD, and other behavioral comorbidities, again, thinking about the alphabet soup as we sort of review and summarize ADHD and OCD or the more more comment of the comorbidities and the other behavior. Comorbidities are also sort of mentioned here. So as we have gone through our Tourettes clinic, our answer was yes for our last two patients. 37:33 So we can treat the behavioral comorbidity or condition. 37:37 Um, but May we may end up treating the text first. Whenever we sort of talked about are our first patient that also had ADHD just recognizing that. one thing that I wanted to mention is that ADHD can frequently be treated with stimulants and simulates can worsen your text. So that’s why I didn’t necessarily use the stimulus to treat his ADHD because it may and most likely will increase their texts. So, with that being said, I usually use a non STEMI that option to treat both. 38:12 And then as we sort of go down, the diagram, they say, are the ticks mild or severe, because it takes happens to be severe like our first type mild, Like our first patient, then we’ll consider the CIT, prophesying quantity. And topiramate can really talk a lot about Topiramate. The pyramid is another medication that can be used in its eight anti seizure medication that can be used for or tips that happened to be mild. 38:38 Going down a little bit further, if we find that those ticks happen to have little or no benefit. Then we can try some of the …: So Tetra … der, … and … 38:48 so those are some of the first line therapies whenever it comes down to sort of mild or severe, mainly sort of ticks that we’re trying to sort of deal with. 39:01 It’s like our last patient, Giovanni going back up and they happen to be full text. That’s where I, sort of Botox sort of comes into play and oftentimes biotechs will remove those vocal tests especially if it happens to be the one that cycles and comes back and forth. 39:17 Sort of going down a little bit further is a second line of agents, which are generally some of the the second generation anti-psychotics. 39:25 So these are the the …, and this is what the area where we use Abilify Risperidone. 39:32 The second line therapy, recognizing that it is quite helpful for tips. We oftentimes are looking into the side effects that may sort of arise as we start to use these medications. 39:44 And so monitoring these medications much more frequently, sometime for grabs and indefinitely, trying to get much of your feedback, or much of my patients feedback, if it comes down to using these medications and making sure that there’s the benefit versus the cost. And that sort of more of a medical cost of using those medications. 40:03 If you still get little to no benefit, our last sort of option for those refractory, difficult to treat Ticks that sort of lead to poor quality of life for Activities of daily Living is the deep brain stimulation. 40:21 So now, as we sort of talked about text, we’ve gone to tick clinic. We’ve talked about the different medication management. The reason why we choose those medications, and some of the side effects and the doses of medications, Let’s talk a little bit about society and culture. 40:35 So what have we talk about Tourette’s Syndrome 20? Sort of mention some very successful people that have Tourette’s Syndrome, like Billy, Irish, the musician. You can see all of her awards there, and she’s somebody, that, I listened to, and happy to. 40:49 So that she’s, you know, conquered her, Tourette’s, and sort of happily mobilize. 40:54 The fact that she has it, as well as Dean …. 40:55 And so who, regardless of whatever desire that you have, you can have your Tourette syndrome and still be somebody that’s a public figure and somebody that is frequently seen despite having no true Stage five. This sometimes can make your tourettes a little bit works. 41:15 Furthermore, whenever it comes down to other people that may be also sort of on a stage, but a different state where there’s Howie Mandel that happens oftentimes be sort of judging others or previously a comedian and sort of a great person that, you know, localized and talked about his battle with Tourette’s? and he also somebody that is a Tourette’s Syndrome person that oftentimes also complains of his OCD. For him, it’s sort of recognized at him, with it’s also sometimes be integer. 41:44 Another person is Grace, Jamie Grace Hopper, which is a young lady here we see at the bottom. She has many of the other comorbidities. She has ADHD, kids OCD. 41:54 She has generalized anxiety disorder disorder, as well as echolalia, and she happens to be a Grammy not nominated young girl that is flourishing in her career as a musician. 42:07 Above her we have David Beckham which is a well renowned soccer star that also sort of tells you about his battles with OCD. 42:18 Then finally, we have Mozart. And so everybody knows him as a composer and well aware of his beautiful music. And so just wanted wanted to mention a few people that we all sort of have seen and or recognize their work that have both Tourette’s Syndrome as well as OCD. 42:37 So here are my my some of my resources? 42:43 And Now I’d say thank you. Thank you for your time and Now’s the time for questions if you have any questions. 42:50 I presume that they are in the chat, and I will look forward to answering them, or you can reach out to me at my Website e-mail or at the office. 43:00 Thank you Alright, thank you, doctor Herd, and we really do appreciate You’re taking the time So we do have a bunch of questions already out there. So give me a minute to gather myself. 43:18 So Have you ever heard of spitting? 43:25 Spitting tick, yes. 43:27 Yeah, So once you get two mm, finished, what you Yep. So once you get to the voice box, I mean, you know, those tags can be a little bit of everything. And so it could sort of result in sort of spitting or some tongue thrusting. 43:41 Those are some of the common ones that some people will admit to. Can you speak to the success rate of habit reversal Therapy? 43:55 The success rate, it definitely depends on the timing. So, just as we sort of talk about the waxing and waning of the of the tick, if you can go to had a reversal therapy, at the same time, in which you are having a sort of more severe, Tiny, as the tick in, which your ERGs oftentimes use, you can find that the reversal of the ERP is helpful. 44:20 And so, it can get you from this Wax theory it to sort of go to the waiting period, not truth for afterwards. 44:29 Is this this inhibition and emotional overload, enrage part of TS, Or does that get associated with ADHD? And does it matter at all where it’s categorized? 44:43 It doesn’t really matter where it’s categorized. I’m trying to sort of re-iterate the fact that the mere add in the spectrum of illnesses in the alphabet soup whether FTS or ADHD or OCD or generalized anxiety disorder or sort of behavioral impulsivity. It’s the impulse. So all of these are along a spectrum of different types of impulses that manifest in different ways, whether it’s a motorcade or local tech, whether it’s anxiety, whether it’s … behaviors. It’s sort of the impulse that it happens to be sort of the foundation of all of these things. 45:22 What are the therapies recommended for this innovation, disinhibition, and, or emotional overload? 45:31 Some of the same therapy used, to be honest with you. 45:34 Whenever I have a child that comes in with impulsivity, and they sort of can’t sort of inhibit themself from doing some of the things that are inappropriate to their environment. I usually do start off with … or quantity. And oftentimes, we’ll sort of increase to a possible anti-psychotic second generation. Depending on their their current response and or side effects. That’s a large portion of my job is just trying to make sure that we can balance between benefits and the side effects to make sure is tolerable. 46:08 Do them do medications effect how CBOT in therapy works? 46:19 Doesn’t make CBOT less effective. No. It doesn’t make it any less effective I mean, I think that a large portion of it is practice and tiny. And so, the medications may sort of take the the tick completely away to where the CBI T May not even be necessary. But, you can do the combination of both. And I usually sort of allow that combination to be what is true for any behavior. So, whether that’s ADHD, sometimes behavior, modification is enough. Sometimes, you need behavior, modification and a medication. And so, this is no different. 46:53 Um, with the Alpha agonistes, Alpha two agonists, do you suggest it in combination with methylphenidate are especially with kids with emotional overload symptoms? Yeah, So, I will do both. So for my kids that really have a hard time with their ADHD and they really feel they need the stimulant, I do sort of warn against all of the side effects. So the stimulus, or, you know, phenomenal for being helpful for ADHD, but oftentimes can make the tips and Tourette’s worse oftentimes can lead to more emotion liability. 47:28 Where they sort of have a let down, I’d oftentimes will compare the stimulants to coffee. For those they drink coffee, whenever you have too much coffee, tend to be a little bit more on edge, you tend to be a little bit more snappy. Instead of when responding to your name with the hello or yes, you may sort of respond with a little bit more snappy like what. 47:46 And oftentimes that some of the side effects that come along with the stimulant. 47:50 And so, sometimes I do have kids that are on the stimulates methylphenidate. Or gets embedded me along with … 48:00 sort of as a polythene fee or treating multiple diagnoses. And so, oftentimes, the feedback is really what I’m looking for, for that, to make sure that they have a better quality of life, with both medications. 48:14 But if I can get a twofer in one medication, for treating two things, what I usually try to do, OK, to first, though, is good. I agree. 48:24 Would be helpful, or helpful, for Tourette Syndrome, with TMS? 48:31 Yes, CMS has been helpful for Tourette syndrome, and so it’s not very many centers. At Boston Children’s, we definitely did TMS. And so, it’s not very many centers that do TMS sort of regularly for it to be something that is as mentioned. I could definitely could have mentioned it here, but yes, it is something that has been used for years. 48:52 What would you suggest for someone who has mainly vocal Turks? 48:58 Um, so oftentimes for the vocal tics, I have found that the the habit reversal therapy is oftentimes helpful. 49:04 And, you know, trying to find a functional sort of voluntary movement. 49:12 And I found for many of my kids that had the vocal tics is trying to sort of, make their tongue go through the roof of their mouth, has been, sort of, the voluntary movement of money. 49:26 What percentage of your patients have received DVB S, or deep brain stimulation? 49:33 So I haven’t had any patients that have acquired deep brain stimulation. So, deep brain stimulation, you know, it’s something that is fairly be going on. Maybe the last 10, 15 years, it sort of started off in the older population, mainly for movement disorders that went along with Parkinson. 49:49 And then, sort of has come down to Tourette syndrome and oftentimes I haven’t necessarily found someone that’s that refractory and sort of hasn’t responded to medications. Again, the environment of bullying and, you know, a huge amount of social distress, may sort of get us to that refractory nature. 50:09 But usually my medications are usually enough for them to sort of, not necessarily need, have to go that far. 50:18 How does regular Guam to scene work compared to the extended release of the same medication? 50:25 Yeah. So it depends. All of these medications depend on your metabolism, whatever it comes down to. Taking the …, we give it at night because of this additive effect of it, and it should work through the majority of the afternoon. 50:38 And so if we sort of start to notice that, they do well during the majority of the functional day, so during the majority of the school day and at home, they have multiple texts but not bothersome to their environment. Then we can sort of say the Waka seen, sort of, has been fully metabolized and their system by four o’clock. 50:55 However, if, after four o’clock, they sort of have multiple clubs and sports, and they still need to have that management, then we’ll sort of either make it twice a day dosing, or will change it to extended release. And again, I’m looking for the feedback to say, OK, and gave it in the morning, we’re not sleepy. We’re still able to function during our school day. 51:14 And then it actually lasts through baseball practice choir theater to where it’s not bothersome during the evening. 51:24 OK, hmm, um, do you have, what are your thoughts on panda’s children and adults? 51:37 So pandas generally is a very controversial sort of illness at Boston Children’s. I definitely have seen kids that have the combination of having a worsening of their text and the setting of a strep infection. But it’s something that has a hard time knowing when to stop. 51:58 So you can continue antibiotics. Some of these kids, you know, legitimately do get better on antibiotics, but antibiotics for a long period of time does have its fair, share of consequences. 52:08 And another sort of mainstay treatment is steroids. 52:12 Equally put, long term steroids can have its fair share of consequences, and so it’s very controversial because it’s hard to know when to stop those treatments and, and how to balance the side effects that may come along with it. 52:28 So, um, there’s a child who was diagnosed with T S at age seven. 52:34 But nowadays, 12 ADHD symptoms are getting in the way, with an emphasis on the attention and memory, Not so much the hyperactivity off label medications haven’t seemed to work, and traditional ADHD meds have been to stimulating. 52:59 It’s been a number of years since they’ve retried medication So would be retry when woodring retrying medications give better results. 53:12 So usually I’ll try to retry meditation, sort of after a cycle of life. 53:17 And so to me, a cycle of life is sort of after 3 or 4 years, and most may be able to retry whether it’s a stimulant. I’m not sure if all of the different categories of stimulants having used the amphetamine, or the open, at eight. 53:30 And then the there’s three different types of majorly used non stem and options that’s the lump of seeing there’s quantity there street terror. And trying to see if any of those medications with different mechanism of actions may be helpful for treating ADHD. 53:48 It is a 30. What I’m going to say is, we’re gonna stay on and continue to answer some questions because we did start a little late. And your doctor heard, you can tell me when your dog or I or I will stop it at a certain point. So thank you, everybody who’s, who’s got other things going on during this time. It needs to jump off. We appreciate that you came on. Don’t forget to fill out the survey, And now we’re going to continue on with questions. 54:25 Um, patients with tears and ADHD. We’re just talking about that. What’s your preferred nerve stimulant? 54:36 I usually try to do the … updates. And so this is usually focal in. 54:40 Usually we’ll start off with the immediate release formulation. 54:42 And then once we sort of get it, general idea about their metabolism, how long it stays in their system before it comes out, and if they are able to deal with some of the side effects than all sort of graduate them to the extended release and improved compliance. 54:57 What’s the dosage of Abilify that generally works in teenage girls? 55:05 Depends on the girl, and again, it oftentimes depends on the metabolism but usually about five milligrams is sort of where I sort of start and then we can sort of go up from there. 55:14 Oftentimes I’m worried the higher the medication dose, the more likely the side effects of increased weight gain and the possibility of the metabolic syndrome that I spoke about before. 55:27 … ever been known to cause anxiety and teens. 55:32 Not necessarily known to cause anxiety is actually the medication that I use whenever somebody experiences anxiety with any of these other diagnoses, So ADHD, anxiety, impulsivity, and anxiety. 55:45 Tourette syndrome anxiety, I usually choose …, because it’s a little bit more calming without removing their personality, which can sometimes be true in some of the other medication choices. 55:57 Since anti-psychotic meds can cause tardive dyskinesia, how can we tell the difference between that And they’re techs? 56:07 Yeah. So, tardive dyskinesia usually, is caused by the medication. So again, remember, Tourette syndrome happens before the age of 18, Tourette syndrome is not something that, that is caused by a medication, generally before the double digits they have seen these ticks. 56:25 The tardive dyskinesia is usually after you’ve been on one of these anti-psychotics for years. 56:30 And so that’s usually how you can sort of identify the diagnosis of tourettes versus tardive dyskinesia. 56:36 The tardive dyskinesia, usually, unlike tourettes, starting your mouth. 56:41 So they’ll, sort of play with their mouth a little bit more. Often, you know, parker their lips play with their lips a little bit more. Often, That sometimes is an issue. And then there’s a little bit more of a tremor aspect. To it. Whenever I think a little bit more about texts, they sort of can be purposeful appearing, movements that happen to not be purposeful. 57:06 So when Abilify causes significant weight gain, but has all that has worked up to this point to control rage, impulse, impulsivity, and explosive behaviors that are comorbid with other ticks. What do you tend to try next? 57:27 So, I may end up trying a different type of anti-psychotic and see if that may possibly be helpful. I didn’t really talk about like Tetra …, which is more used for movement disorders. Moreso so, the motion. So, the motor text. So, it may sort of try to see if I can go backwards to Tetra … and see if that happens to be helpful because that’s not a common step. Usually it’s usually the F agonists down to the anti-psychotics and so Tetra … it’s sort of been around a little bit more in-between the creation of the first generation anti-psychotics and the creation of a second generation anti-psychotics. So I’ll try … 58:04 with a different mechanism of action, without those side effects to see if that possibly could be a solution for them. 58:15 Um, what’s the mask maximum dosage of gorm for seeing that can be used in an adult? 58:24 Adults is a little bit right now, outside of my realm a tad bit, because I do Pieds. 58:28 However, It’s usually sort of based on side effects. You know, there’s oftentimes a general range, and this is how we sort of operate in medicine, is a general therapeutic range that exist. And that ranges depended upon side effects. I have seen want the scene that have used up to six milligrams. Again, these are in kids. So as we sort of get to 18, 18 year old can be as large as a 25 year old or we’re happy. So, it sort of depends on the side effects. So, if we go up to, I’m making this up 10 milligrams and they happen to be sleepy, then sort of continue to monitor and watch …, is in a category of an alpha two agonists, which initially was used as a hypertensive medication or medication that’s used for hypertension. And it can lower your blood pressure. So, that would be something else that I would notice to pay attention to you a little bit more in adults than it really don’t see a lot in kids. 59:25 My 16 year old is not not aware of the per mandatory urges at this time would have it Riverside, be even worth trying. 59:37 Not fully because you really need to have that urge to practice the urge with the involuntary movement. sorry, with the voluntary movement. And so without that urge, head reversal therapy may not be helpful. However, pattern reversal, as I said, is under the umbrella of cognitive behavioral interventions and Z to do the other things, relaxation techniques. 59:58 Removing some of the environmental issues that caused the text to become a little bit more predominant, that would be helpful. 1:00:09 You can e-mail info at … dot org if you live. In the New Jersey area, we have lists of cognitive behavioral intervention. 1:00:20 Therapists are people who have been trained. 1:00:26 Poor. 1:00:28 The tech treatment you mentioned, Abilify being one of your go tos. Please elaborate. 1:00:35 That’s if we get down to the anti-psychotics, my initial goto is usually the alpha two agonists and that will be the quantity and the …. You see go to the … first just because it happens to be a little bit more benign, a little bit more easily. Tolerated and does have that extended release option. 1:00:55 Do you think neuro or biofeedback be helpful for two years? 1:01:00 It can be. But I will say that it depends on who’s offering it. 1:01:06 And so it’s something that happens to be controversial. Sometimes, multiple sessions are needed. And it can be a little bit expensive. It’s not always covered by insurance. If you find it to be helpful, you know, go with it. 1:01:18 But it’s not something that I can easily and readily say, that is also always going to be the best bang for your buck. 1:01:29 Do you feel genetic testing for medications is useful or beneficial for treatment? 1:01:35 Yeah. So pharmacogenomics can be helpful to give you a general idea of what I sometimes am asking, hearing my feedback sessions. It lets us know what you metabolize. Well, which you metabolize quickly. And so, like I say, I usually sort of start you off in somewhere in that therapeutic window. And so if this is a window you sort of start off here for me. You can sort of advance somewhere in-between that window. But pharmacogenomics, me let me know that you are slow metabolizing. So because you’re slow metabolizing to hold onto the medication or long period of time, you’re going to need a lower amount for that medication. 1:02:07 Your fast metabolism, then it’s going to be very easy for you to quickly get to the upper end of that. That window, it’s helpful. 1:02:15 I think, more for your for the mental health piece of it. Sometimes if you’re a fast metabolize, or, and we’re having to go up on the dose, you would recognize that it’s not because I’m refractory, or, it’s a more severe case. It’s just because I’m not going to respond until I get to this higher dose. And I think that that’s helpful. 1:02:35 You ever treated … with an SSRI or …. 1:02:40 Yeah, so oftentimes I use SSRI’s or …. Thanks for mentioning that, especially whenever the, the anxiety is an issue. 1:02:49 It sometimes takes a longer period of time for you to get that effect, and that’s why I didn’t really mention it here, because SSRI’s an S in our eyes, usually take 4 to 6 weeks for you to get that optimal peak of that. 1:03:01 And oftentimes you’re coming to me, because this is something that’s bothering you, you know, on a day to day. And so, for me, to save it, I wanna give you this medication, and 4 to 6 weeks is whenever you’re gonna start to see some of the benefits UC. Would like for that benefit to happen sooner rather than later. 1:03:18 And so that’s why the SSRI’s, the ones that I’d use initially. But if you happen to already be on SSRI, usually I’ll try to sort of advanced by going up on it. You try to see if I can just to sort of relief and or treatment sooner rather than later. 1:03:35 You haven’t mentioned true candy. 1:03:38 Our doctor prescribed this have you used this before with Tourette syndrome? 1:03:43 So true. Kidney was sort of mentioned when I talk about to appear me, so told me are made in Agile Kennedy. They’re sort of in the fam. same family, their cousins. 1:03:50 So to a pyramid is the initial sort of first molecule that’s sort of used. … There’s another one that It has a little bit of a difference with the extended release formulation as we give a name for attendees to appear mate topamax. Those are all sort of the same family. So I do use those. 1:04:10 They also have some sites sometimes are a little bit harder to understand in the population that we’re using these kids. 1:04:17 Sometimes topamax can cause you to have some mental fogginess, and mental dolny donis, that sometimes the younger kids may not necessarily know how to identify some sort of Barry Choosey on the kids that would be able to identify that. 1:04:33 Make sure that they’re going to give me that feedback, that they have some cognitive difficulties that they recognize the face on the medication. 1:04:43 Um, have you seen hypothyroidism associated with tears? Or It is my son who’s been battling now for six years with TS just lucky one, who happened to have it masked by his symptoms. 1:05:03 It’s not a common association. 1:05:06 So hypothyroidism is what they were saying Right Oh, yes, yes, yes, well, hypothyroidism sorta usually results in sort of other manifestations. That’s usually not movement related. So, usually I have a slower metabolism. Sometimes it results in weight gain. Sometimes they have some mental fogging mental dullness of changes in their skin. 1:05:31 Difficulty with their metabolism to wear. 1:05:35 Know, that that’s where the weight gain comes from, but it’s sort of having its association with Tourette’s. 1:05:41 I wouldn’t say that that was a correlation, that is common, OK. 1:05:46 Um, I’m not sure what they mean. The question says, is it possible to get rid of … through surgery and I’m assuming that means deep brain because that’s the only surgery I know. 1:06:02 Yeah. So, it is possible. I’m hoping that there are other medications that can get there before the deep brain stimulator is needed. 1:06:12 But it’s not a change on the brain. That is a structural change. 1:06:17 If you remove that area like we can sometimes do with epilepsy, it’s not a a certain area of the brain if you reset and cheers you of your T S. 1:06:27 That’s what they’re asking for. 1:06:29 Direct recommend Taking Abilify at night or in the morning. 1:06:33 Abilify usually makes you a little bit sleepy. So I usually would say ticket at night. And then sort of depends on your sort of metabolism as to it sort of can wrap around to the next day to give you the benefits of it during the day. 1:06:48 I think this is a good place to end our questions. Any questions that were posed that did not get answered, tonight, I will put on our blog. And you can go to our website at WWW dot … dot org, under Programs, and you can find the blog. So I know I appreciate you taking the time, doctor Herb, or planning this webinar. Retooling it. 1:07:29 And helping us out tonight on medication management. 1:07:34 There are. 1:07:35 So thank you for joining us. Everyone, Thank you for joining our webinar on Medication Management and Tourette Syndrome and Co-occurring Disorders. 1:07:45 There is an exit survey, which we need everyone attending to fill out, and the webinar blog is now open and available for the next seven days on the MJ CTAS Web site, for any additional questions not covered in tonight’s presentation. 1:08:03 Also, an archived version of this webinar will be posted to our website, as well as e-mailed to all the participants. 1:08:13 So, our next presentation is attentional and neuropsychological difficulties Experienced with epilepsy. Surprise, you’re not doing that. It will be presented by doctor Hillary Murphy, and is scheduled for June first, 2022. This ends tonight’s webinar. Thank you, doctor heard for your presentation. Thank you, everyone for attending tonight.