Tic Disorders

Tics are movements or sounds that happen suddenly, without rhythm, and over and over again. When a child or teen gets a tic, it can be scary for caregivers. They might worry if the little coughs or blinks will ever stop or if they mean something more serious. If a child has a tic, experts suggest seeing a doctor to make sure it is a tic. But most of the time, parents are told to watch and wait before doing anything else. Treatment is only needed when tics become long-lasting and cause problems.

What are the symptoms of a Tic Disorder?

Tics are quick, repeated movements or sounds. Most are called “simple” tics, which means they are one movement, like a squint or a quick head nod. Some are called “complex” tics, which means they are bigger combinations of movements or sounds, like reaching up and shaking your head, or a blink followed by throat clearing.

Motor Tics

– Shoulder shrugging

– Eye blinking

– Lip biting

– Facial grimacing

Vocal Tics

– Clearing the throat

– Humming, sniffing, snorting, or squealing

– Repeating words

There are different types of Tic Disorders, each with slightly different symptoms:

– Provisional Tic Disorder: Involves single or multiple motor and/or vocal tics that have been present for less than one year.

– Persistent (Chronic) Motor or Vocal Tic Disorder: Involves single or multiple motor or vocal tics, but not both, that have been present for more than one year.

– Tourette’s Disorder: Involves both multiple motor and one or more vocal tics that have been present for more than one year.

A child’s or teen’s tics may come and go over time, but the tics must start before 18 years of age. Also, the tics must not be caused by a substance or a medical condition to be diagnosed as a Tic Disorder.

How are Tic Disorders diagnosed?

A doctor will diagnose a child or teen with a Tic Disorder after checking if the movements or sounds meet the diagnostic criteria and how long the tics have lasted.

The child-adolescent psychiatrist may interview and/or assess both the child or teen and a caregiver to figure out the specific nature of the tics. The practitioner will also try to determine that the tics are not related to something unexpected.

Tic Disorder facts

Worldwide frequency of the condition:
Tics are present in approximately 0.03% to 3% of the global population, and Tourette’s Disorder affects approximately 0.03% to 0.77%. Currently, there is no representative national data in Brazil.

Gender ratio:
The comparative data for boys and girls range from 2:1 to 4:1 for tics and Tourette’s Disorder.

Peak age of onset:
Tics tend to begin in childhood, between 4 and 6 years of age, with a peak between 10 and 12 years of age. The average age of onset for neurodevelopmental disorders, in general, is 5.5 years.

Proportion of the condition that emerges before age 18:
Tics that are not caused by a substance or medical condition must begin before age 18. Therefore, 100% of individuals with Tic Disorder will be diagnosed by age 18. In comparison, the proportion of neurodevelopmental disorders in general (including Tic Disorders) that begin before age 18 is 83.2%.

What are the associated factors for Tic Disorders?

Some common factors linked with Tic Disorders are:

– Genetic and familial factors: Most likely a combination of multiple genes interacting with environmental factors.

– Developmental factors: These include premature birth and low birth weight.

– Complications during pregnancy: These include nicotine or caffeine use during pregnancy.

– Complications during childbirth: These include lack of oxygen (hypoxia).

– Environmental factors: Excitement, anxiety, or tiredness may make tics worse.

– Infections and immune response: Pediatric acute-onset neuropsychiatric syndrome (PANS) results from a bacterial or viral infection, triggering an autoimmune response in certain children. Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) is a specific subtype of PANS resulting from a streptococcal infection. The symptoms of PANS and PANDAS are sudden tics, OCD symptoms, and mood swings.

What other disorders co-occur with Tic Disorders?

Even though each child and teen is different, Tic Disorders might often happen with other mental health disorders, including ADHD and OCD.

How are Tic Disorders treated?

Tic Disorders are usually treated with therapy or a combination of therapy and medication.

Therapy for Tic Disorder often involves cognitive-behavioral therapy (CBT) with a part called habit reversal training (HRT). If a child gets a feeling before a tic, they’re taught to recognize it and identify situations that may trigger it. The child and therapist develop a “competing” response—an action the child does when they feel the urge—that is different from the tic and less noticeable to others. For example, a child whose tic involves sniffing their nose may do a breathing exercise instead. Kids may also learn relaxation techniques to decrease the frequency of the tics. Another part of CBT, exposure and response prevention (ERP), helps kids prevent tics by learning about and resisting the feelings they get before their tics happen. When kids resist tics for a long time, they learn to handle the warning feelings better (i.e., habituation).

Children and teens with Tic Disorders tend to respond well to certain medications, especially when symptoms are moderate to severe. The medication most commonly used is called aripiprazole. While other types of medications have been studied as well (such as risperidone and tiapride), evidence of their effectiveness for kids is limited. When symptoms occur with Attention Deficit-Hyperactivity Disorder, medications such as clonidine and guanfacine can also be considered. Medications can have side effects, but they are safe for kids to use with proper monitoring by their doctor and close supervision from their caregivers. A child or teen taking one of these medications should see their doctor regularly, especially if their dosage has recently changed.

The combination of CBT and medication can also be considered.

References

Clinical description, symptoms, and diagnostic information

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Child Mind Institute. (2021, September 7). Quick guide to Tourette’s Disorder. _https://childmind.org/guide/quick-guide-to-tourettes-disorder/_

– Child Mind Institute. (2022, December 20). Quick guide to chronic motor or vocal tic disorder. _https://childmind.org/guide/what-is-chronic-motor-or-vocal-tic-disorder/_

– Jacobson, R. (2022, December 20). Tics and Tourette’s: What to do (and not do) if your child develops a tic. _https://childmind.org/article/tics-and-tourettes/_

– World Health Organization. (2022, February). ICD-11 for mortality and morbidity statistics. 8A05.00 Tourette Syndrome. _https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f119340957_

– World Health Organization. (2022, February). ICD-11 for mortality and morbidity statistics. 8A05.01 Chronic Motor Tic Disorder. _https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1649340159_

– World Health Organization. (2022, February). ICD-11 for mortality and morbidity statistics. 8A05.02 Chronic Phonic Tic Disorder. _https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f169010223_

Facts

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Institute for Health Metrics and Evaluation (IHME). (2019). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington. Available from _http://vizhub.healthdata.org/gbd-compare_. (Accessed 11/15/2022)

– Kendler, K. S. (2013). What psychiatric genetics has taught us about the nature of psychiatric illness and what is left to learn. Molecular Psychiatry, 18(10), 1058–1066. _https://doi.org/10.1038/mp.2013.50_

– Knight, T., Steeves, T., Day, L., Lowerison, M., Jette, N., & Pringsheim, T. (2012). Prevalence of Tic Disorders: A Systematic Review and Meta-Analysis. Pediatric Neurology, 47(2), 77–90. _https://doi.org/10.1016/j.pediatrneurol.2012.05.002_

– Scharf, J. M., Miller, L. L., Gauvin, C. A., Alabiso, J., Mathews, C. A., & Ben-Shlomo, Y. (2015). Population prevalence of Tourette syndrome: A systematic review and meta-analysis: Meta-Analysis of TS Prevalence. Movement Disorders, 30(2), 221–228. _https://doi.org/10.1002/mds.26089_

– Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G., Il Shin, J., Kirkbride, J. B., Jones, P., Kim, J. H., Kim, J. Y., Carvalho, A. F., Seeman, M. V., Correll, C. U., & Fusar-Poli, P. (2022). Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry, 27(1), 281–295. _https://doi.org/10.1038/s41380-021-01161-7_

– Ueda, K., & Black, K. J. (2021). A Comprehensive Review of Tic Disorders in Children. Journal of Clinical Medicine, 10(11), 2479. _https://doi.org/10.3390/jcm10112479_

Associated factors

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Chao, T.-K., Hu, J., & Pringsheim, T. (2014). Prenatal risk factors for Tourette Syndrome: A systematic review. BMC Pregnancy and Childbirth, 14(1), 53. _https://doi.org/10.1186/1471-2393-14-53_

– Child Mind Institute. (2023, February 23). Complete guide to PANS and PANDAS. _https://childmind.org/guide/parents-guide-to-pans-and-pandas/_

– Girgis, J., & Pringsheim, T. (2020). Prenatal Risk Factors for Tourette Syndrome: A Systematic Review Update. Current Developmental Disorders Reports, 7(4), 258–269. _https://doi.org/10.1007/s40474-020-00217-7_

– Jiang, J., Chen, M., Huang, H., & Chen, Y. (2022). The Aetiology of Tourette Syndrome and Chronic Tic Disorder in Children and Adolescents: A Comprehensive Systematic Review of Case-Control Studies. Brain Sciences, 12(9), 1202. _https://doi.org/10.3390/brainsci12091202_

– Kendler, K. S. (2013). What psychiatric genetics has taught us about the nature of psychiatric illness and what is left to learn. Molecular Psychiatry, 18(10), 1058–1066. _https://doi.org/10.1038/mp.2013.50_

– Ueda, K., & Black, K. J. (2021). A Comprehensive Review of Tic Disorders in Children. Journal of Clinical Medicine, 10(11), 2479. _https://doi.org/10.3390/jcm10112479_

Co-occurring disorders

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Hirschtritt, M. E., Lee, P. C., Pauls, D. L., Dion, Y., Grados, M. A., Illmann, C., King, R. A., Sandor, P., McMahon, W. M., Lyon, G. J., Cath, D. C., Kurlan, R., Robertson, M. M., Osiecki, L., Scharf, J. M., & Mathews, C. A. (2015). Lifetime Prevalence, Age of Risk, and Genetic Relationships of Comorbid Psychiatric Disorders in Tourette Syndrome. JAMA Psychiatry, 72(4), 325. _https://doi.org/10.1001/jamapsychiatry.2014.2650_

– Kloft, L., Steinel, T., & Kathmann, N. (2018). Systematic review of co-occurring OCD and TD: Evidence for a tic-related OCD subtype? Neuroscience & Biobehavioral Reviews, 95, 280–314. _https://doi.org/10.1016/j.neubiorev.2018.09.021_

– Rothenberger, A., & Heinrich, H. (2022). Co-Occurrence of Tic Disorders and Attention-Deficit/Hyperactivity Disorder—Does It Reflect a Common Neurobiological Background? Biomedicines, 10(11), 2950. _https://doi.org/10.3390/biomedicines10112950_

Interventions

– Andrén, P., Jakubovski, E., Murphy, T. L., Woitecki, K., Tarnok, Z., Zimmerman-Brenner, S., van de Griendt, J., Debes, N. M., Viefhaus, P., Robinson, S., Roessner, V., Ganos, C., Szejko, N., Müller-Vahl, K. R., Cath, D., Hartmann, A., & Verdellen, C. (2022). European clinical guidelines for Tourette syndrome and other tic disorders—version 2.0. Part II: Psychological interventions. European Child & Adolescent Psychiatry, 31(3), 403–423. _https://doi.org/10.1007/s00787-021-01845-z_

– Besag, F. M., Vasey, M. J., Lao, K. S., Chowdhury, U., & Stern, J. S. (2021). Pharmacological treatment for Tourette syndrome in children and adults: What is the quality of the evidence? A systematic review. Journal of Psychopharmacology, 35(9), 1037–1061. _https://doi.org/10.1177/02698811211032445_

– Farhat, L. C., Behling, E., Landeros-Weisenberger, A., Levine, J. L. S., Macul Ferreira de Barros, P., Wang, Z., & Bloch, M. H. (2022). Comparative efficacy, tolerability, and acceptability of pharmacological interventions for the treatment of children, adolescents, and young adults with Tourette’s syndrome: A systematic review and network meta-analysis. The Lancet Child & Adolescent Health. _https://doi.org/10.1016/S2352-4642(22)00316-900316-9)_

– Pringsheim, T., Holler-Managan, Y., Okun, M. S., Jankovic, J., Piacentini, J., Cavanna, A. E., Martino, D., Müller-Vahl, K., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., & Oskoui, M. (2019). Comprehensive systematic review summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 907–915. _https://doi.org/10.1212/WNL.0000000000007467_

– Pringsheim, T. (2017). Tic Severity and Treatment in Children: The Effect of Comorbid Attention Deficit Hyperactivity Disorder and Obsessive Compulsive Behaviors. Child Psychiatry & Human Development, 48(6), 960–966. _https://doi.org/10.1007/s10578-017-0718-z_

– Roessner, V., Eichele, H., Stern, J. S., Skov, L., Rizzo, R., Debes, N. M., Nagy, P., Cavanna, A. E., Termine, C., Ganos, C., Münchau, A., Szejko, N., Cath, D., Müller-Vahl, K. R., Verdellen, C., Hartmann, A., Rothenberger, A., Hoekstra, P. J., & Plessen, K. J. (2022). European clinical guidelines for Tourette syndrome and other tic disorders—version 2.0. Part III: Pharmacological treatment. European Child & Adolescent Psychiatry, 31(3), 425–441. _https://doi.org/10.1007/s00787-021-01899-z_

– Ueda, K., & Black, K. J. (2021). A comprehensive review of tic disorders in children. Journal of Clinical Medicine, 10(11), 2479. _https://doi.org/10.3390/jcm10112479_