The family of a 9-year-old girl stated that their daughter has had tics (clearing sounds from her throat), and various repetitive behaviors such as stepping and heel tapping while walking, for the past 4 years since she started kindergarten. They noted that she had difficulty learning to read when she started primary school, that she had attention deficit disorder, and that medication only controlled less than 50% of these tics, and they never completely disappeared.

Her teacher stated that she did not have attention deficit disorder, that she was successful in class, and that she did not engage in behaviors such as talking during class, playing with pens and erasers, dropping objects, or scribbling. However, it was noted that she did not sit down to study alone at home or read books. Her family added that she sometimes ranked eighth in her class and sometimes twenty-second, that her reading was slow, that she didn't skip lines while reading, but that she couldn't fully explain what she read.

It was learned that she goes to bed at 9:30 pm and wakes up at 7 am feeling refreshed, that her energy level is normal, that she has momentary irritability throughout the day, that she cries and complains, and then calms down. It was said that he had problems in his relationships with his friends, that he could express himself but had difficulty expressing himself during arguments, and that he lied occasionally.

The family had applied for non-drug neurofeedback therapy:

Regarding the child's history before and after birth, it was learned that the birth was normal, the mother's pregnancy was normal, but she smoked during pregnancy and did not breastfeed after birth.

Head injury history: It was stated that a friend hit the child on the head, causing the child to hit the head violently against a wall, and that the child suffered facial paralysis at the age of 3-4.

Medications used: In 2004, at the age of 5, for attention deficit and tics,

Antipsychotic medication (one from the Risperidone and one from the Pimozide group) and

Methamphetamine.

Medications: It was learned that the child currently takes 1mg of Pimozide daily, 10mg of a Metamphetamine twice daily, and

once daily for the past 3 months.

 

Medications: When the family's psychiatric history was examined, it was learned that the grandmother had schizophrenia and the mother had received treatment for manic depression and is now doing well.

 

DIAGNOSIS: The child, who was thought to require investigation for Tourette syndrome, learning disabilities, and Attention Deficit Disorder, was given the following tests:

-WISC-R,

-TOVA,

-QEEG, and

-C.A.T. and Louisa-Düss tests

-Laboratory tests were ordered.

 

WISC-R TEST: To understand the child's situation compared to their peers, the WISC-R was ordered. Accordingly,

Verbal Test IQ Score was determined as 108,

Performance Test IQ Score as 102, and

Total Test IQ Score as 106 (according to 1980 Turkish norms).

A difference of 6 points was found between the Verbal and Performance test scores.

C.A.T. and Louisa-Düss Tests: Examining the C.A.T. and Louisa-Düss tests, which are conducted to gain insight into the child's inner world, it was observed that the child's stories included a parent-child triangle, that the child's needs were met by the mother, and that the mother was seen as an authority figure. Although the child did not see himself alongside his father, he aimed to cooperate with him, and the father was seen as a leader in the child's eyes. It was learned that the child showed curiosity and sometimes unease when the parents were close, but was able to cope with this situation. While no sibling rivalry was observed, it was thought that he gave clues that he wanted to be an authority figure when he had a sibling. He perceived the outside world as dangerous, but found the strength within himself to cope with it. He sometimes felt unwanted by people, but still developed self-confidence. He feared darkness and losing his parents, and finally, he was able to convey intergenerational and gender awareness and position himself accordingly.

 

QEEG: After the initial consultation, a QEEG was performed to identify irregularities in electrical activity and to determine if neurofeedback would be applied. When this QEEG was compared with that of her peers using a neurometric analysis system, it suggested learning difficulties. Suspicious slowing was observed in the QEEG taken with her eyes closed, so a sleep EEG was also requested.

SLEEP EEG (UEEG): Spike activity was observed in the UEEG. Therefore, considering whether the epileptic activity was related to a cellular disorder in the brain, we requested a brain MRI, and the result was normal.

 

To record the QEEG without medication, the medication was discontinued for 7 half-life periods.

It was reported that her tics increased since stopping the medication, but for the last 15 days she has been more lively, more outgoing, and less irritable. It was thought that these changes occurred because the side effects in the brain disappeared with the discontinuation of the medication. While the medication was beneficial in some ways, it was also causing side effects.

Tourette (Chronic Tic Disorder) Neurofeedback Treatment

After 9 hours of Neurofeedback: During the consultation, it was learned that the tics, which had increased at the beginning of treatment, had decreased; the repetitive hitting motion in the groin had started, but this movement was infrequent; and that tics such as throat clearing, stepping, and heel tapping had disappeared.

 

It was noted that his grades were good, he had no mistakes on the Turkish exam, he read when instructed, his reading speed had increased, and he could explain what he read better.

 

It was stated that after stopping the medication, his irritability disappeared, his cheerfulness increased, he followed instructions, he was less insistent, and he could express himself during arguments and didn't freeze up.

 

After 20 hours of Neurofeedback sessions: In the interview, the family stated that they were very satisfied with the treatment, that the tics and groin tapping had stopped, that while they used to do addition and subtraction with their fingers, they could now do calculations mentally,

that they were doing well in their stud

ies, that their teacher was very pleased with them,

that they were reading books, that while they used to have difficulty reading some words, this had ended after the treatment, that they could explain what they read, that they were no longer irritable or insistent, that they were cheerful, and that they followed instructions. It was also reported that their sleep was normal, that they were relaxed during discussions, that they didn't freeze up, and that they didn't lie.

After 30 hours of Neurofeedback sessions: In the interview...

During the interview, the family stated that tics (head shaking) reappeared after 20 sessions, but have become much less frequent in the last week, and other improvements continue. They reported that the child attends swimming lessons and, while previously unable to swim breaststroke, can now do so after treatment. It was also noted that while the child used to get bored solving puzzles, they now solve them more quickly and easily. Furthermore, it was added that the child reads books when asked to.

 

After 40 hours of Neurofeedback sessions: The interview indicated that the child's sleep EEG had normalized, their tics were gone, they were able to play with friends for 3-6 hours without complaint, their anger, crying, and irritability had disappeared, and they were less talkative.

A follow-up appointment was recommended.

 

Did the medication they were using cause side effects? The irregularities in the sleep EEG likely contributed to their complaints. Neurofeedback therapy demonstrates that operant learning is also effective in the unconscious sleep phase (Sterman M.B. 1980, 1982). The fact that neurofeedback therapy normalizes these spike activations in the UEEG without medication proves that this treatment method does not have a placebo effect. The medications he was taking before coming to us (Risperidone, Pimozide, and Metamphetamine) were likely triggering these irregularities and further increasing his restlessness and aggression.

The family reported to us that their child started to be happier after stopping the medication and before starting neurofeedback therapy.

Personalized, Appropriate Treatment Method is Necessary:

As seen in this case, an appropriate treatment method must be included in daily treatment, and I understand the complaints of doctors who have to see patients for 15-20 minutes to eliminate the reason why diagnoses and medications given without detailed brain research are ineffective. This type of research could improve the success of medicine and prevent our patients from wasting years. This patient has not improved with medication for 4 years and has worsened in behavior and learning.

However, if we start using personalized treatment methods more frequently, we can increase our chances of success in other patients, just as the 2-month drug-free NF treatment here led to improvement.

The patient was given medication with significant side effects from the age of 5, and even though they did not fully recover, they continued taking the medication. The waiting period to understand whether the medication is effective is 1-7 days for amphetamine-group drugs, 15-30 days for antipsychotic-group drugs, and 3-6 weeks for antidepressants.

The scientific validity and ethical compliance of a drug treatment that has been applied for 5 years without success and continued despite this should be questioned. These years are of great importance for students; we must ensure that they achieve academic success as soon as possible and move to the next grade without developing a lack of knowledge.

Follow-up:
At a follow-up appointment one month after treatment, it was learned that the child's symptoms had not returned, that he was studying, doing well in his studies, doing his homework more accurately, being patient, that he no longer had tics, that he was reading books, and that he was doing math calculations more practically. The mother reported that his frog-style swimming skills had improved after NF treatment.

A follow-up appointment and a repeat WISC-R test were requested 45 days after the start of school.

**Increased Score in Repeat WISC-R Test:**
In the second WISC-R test, conducted 7 months after the first, the Verbal Test IQ score was determined as 116, the Performance Test IQ score as 104, and the Total Test IQ score as 112 (according to 1980 Turkish norms). Following NF treatment, an increase of 8 points in the Verbal Test IQ score, 2 points in the Performance Test IQ score, and 6 points in the Total Test IQ score was observed. There was no regression in any of his symptoms. The family is quite pleased. When he comes home, he studies, all his grades are 4. He has no tics, no aggression. Repeated Sleep EEG is normal.

TOVA Test Repetition:
Before treatment, there were impulsivity errors in the Auditory TOVA test; with this treatment, it reached normal levels. Conduction Velocity was slow in the first 15 minutes. Although there is a partial improvement here, irregularity is still present. We see that the patient, whose Conduction Velocity Variability was disrupted in the first 15 minutes, normalized this with neurofeedback treatment.

QEEG Change with Neurofeedback Treatment:

Before treatment, absolute alpha and beta were higher than normal, relative alpha was higher than normal, and alpha and beta hypercoherence abnormalities were detected. With treatment, the significant decrease in alpha and the partial decrease in beta suggest that the treatment has had a positive effect.

 

In Stage I sleep, along with slowing and sharp vertex waves, spike-slow wave discharges with an amplitude of 150-200 mV and a duration of 0.2-0.3 seconds were observed, starting in the Fp1-Fp2, F3-Fz-F4, C3-Cz-C4 regions and then spreading to irritate the temporal and parietal regions. Conclusion: Fronto-Temporal epileptiform activity?

Before treatment, the amplitude values ​​of spike activity in the right frontotemporal region were 30-50 mV higher than in the left hemisphere.

The spike activity was elevated. After treatment, the amplitude values of spike activity in the right frontal temporal region are no higher than in the left hemisphere.