Hindawi Publishing Corporation Case Reports in Psychiatry Volume 2012, Article ID 497160, 3 pages doi:10.1155/2012/497160 Case Report Management of Severe Pediatric Tourette Syndrome Resistant to Drug Treatment Hemamali Perera1, 2 and Chittahari Abayanayaka1 1 University Psychological Medicine Unit, Lady Ridgeway Hospital for Children, Colombo 08, Sri Lanka 2 Department of Psychological Medicine, Faculty of Medicine, University of Colombo, Kinsey Road, Colombo 08, Sri Lanka Correspondence should be addressed to Hemamali Perera, hemamali p@yahoo.com Received 30 July 2012; Accepted 28 August 2012 Academic Editors: M. Kluge, C. Lanc¸on, and H. Onishi Copyright © 2012 H. Perera and C. Abayanayaka. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Tourette syndrome (TS) is a neurodevelopmental disorder with chronic and disabling impacts on multiple domains of functioning in children. Treatment of TS is often complicated by comorbid conditions. We present a 12-year-old boy with severe symptoms of Tourette syndrome (TS), with prominent and markedly disabling vocal tics, who failed to respond to substantial doses of risperidone and haloperidol, given for a prolonged period. Satisfactory outcome was achieved with exposure and response prevention, adjunct to medication. Comorbid ADHD was treated with stimulants with no exacerbation of tics. 1. Introduction Tourette syndrome (TS) is a neurodevelopmental disorder with a chronic course and is characterized by complex motor and vocal tics [1]. Age of onset of TS is childhood, usually 5 to 10 years of age with a male to female ratio of 5 : 1. Onset of TS is usually with simple motor tics at around 5 years while onset of vocal tics occurs around 8 to 15 years. Tic severity peak in early to mid adolescence and comparatively less in adulthood [2]. Though the main treatment option for TS is pharmacological, management is often complicated by comorbid conditions [3]. Accordingly, among children with TS, attention deﬁcit hyperactivity disorder (ADHD) is found in 64%, behavioral problems such as oppositional deﬁant disorder (ODD) or conduct disorder (CD) in 43%, anxiety problems in 40%, depression 36%, and developmental delay in 28% [4]. Obsessive-compulsive behaviors and obsessive-compulsive disorder (OCD) have been shown to occur among more than one-third of persons with TS [5]. We present a case of an adolescent with severe TS and multiple comorbidities, refractory to pharmacological ther- apy alone. Our aim is to describe the details of exposure and response prevention (ERP) used in adjunct to medication, to achieve successful symptom control short- and long-term. 2. Case Presentation R, a 12-year-old schoolboy and the ﬁrst born child of nonconsanguineous parents, carried a diagnosis of TS since 8 years of age. He had motor tics aﬀecting the neck, shoulders, and facial grimacing. The most prominent symptom was a very loud bark-like vocalization, which could be heard from some distance away. The vocal tics occurred as frequently as 2-3 times a minute and were highly socially disabling. He presented to our child and adolescent mental health service (outside his area of residence) for the ﬁrst time at the age of 11 years due to persistence of symptoms despite ongoing treatment. The following details are based on our contact with R. and his parents. 2.1. History. R’s symptoms ﬁrst appeared at the age of 8 years, initially as excessive blinking, which later progressed to jerky repetitive movements involving head and neck regions. The bark-like vocal utterances ﬁrst appeared 3 years before, which had become louder and more frequent with time.