Olivia, 7, has been brought to the emergency department.

Over the last couple of weeks, Olivia has been having episodes of rapid blinking and grimacing. They only occur when she’s awake. She does not lose awareness, and her activities are not impaired. Olivia feels she can stop them from happening, but she feels better if she lets them happen. She is otherwise completely well.

They visited the GP, who advised them that Olivia was having tics. Her mother has brought her to the emergency department because she is worried that Olivia is doing the movements more frequently and would like a brain scan.

What are tics?

Tics are the most common type of paediatric movement disorder. They are sudden, quick, non-rhythmic and recurrent movements or vocalisations.

The three main features of tics are:

– That they are suggestible
– There is a premonitory urge. The child experiences unpleasant sensations or tension that are relieved by the tic.
– They can be temporarily suppressed, but the premonitory urge increases.

Periods of stress can increase the frequency of tics, and they can disappear on their own, often described as ‘waxing and waning.’ When they interrupt a person’s voluntary actions, they are called ‘blocking tics.’

What do tics look like?

Motor tics

Simple motor tics

• Involve one muscle group or body part
• Appears non-purposeful

They may be :

• Clonic: rapid movements such as blinking
• Dystonic: slower, such as slow mouth opening
• Tonic: tensing muscle groups such as the abdomen or limbs

Complex motor

• Involves several muscle group
• May seem purposeful

Examples include mimicking other people’s movements or performing obscene gestures.

Vocal tics

Simple vocal

• Sounds made by the nose, mouth, or throat with no meaningExamples include coughing or grunting

Complex vocal

• Saying words or phrasesExamples include mimicking speech or saying obscene words

Types of tic disorders

There are five main types.

The first three always start before 18 years of age.

Provisional

Motor or vocal tics present <1 year

Persistent

Motor or vocal tic persistent for over a year

Tourettes

Presence of both motor and vocal tics (not necessarily at the same time) and persistent over a year

Other

Does not meet the above criteria and the reason provided – e.g. onset after 18 years.

Unspecified

Does not meet above criteria and reason not provided

Who gets tics?

The average age for diagnosis is 5 years old, and these conditions are more common in boys. If diagnosed with a chronic tic disorder, symptoms are typically most severe between the ages of 8 and 12 years.

Why do children get tics?

Family studies have shown that tics have a genetic element, and although researchers have implicated several genes, they have not identified a specific one. Researchers have also linked environmental factors, such as smoking during pregnancy and poor economic background, to tic disorders. However, these studies are not robust enough to provide definitive conclusions.

Various components of the immune system have been associated with tics. In particular, infections with β-haemolytic streptococcus were once proposed as part of the mechanism behind Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS).

In short, we know that a combination of genetic, environmental, and immune factors causes tics, even though we don’t know the specifics.

What other conditions are associated with tics?

Tics are associated with other conditions. These are often more problematic than the tic itself.

What other things look like tics?

Some conditions look like tics. It can be difficult to tease them apart as some, like compulsions, can coexist.

You confirm that Olivia has simple motor tics of a clonic and dystonic nature. Your screening questions do not identify any other associated conditions.

You reassure her that Olivia does indeed have tics and does not need a brain scan.

The movements may be more frequent when more attention is drawn to them as they are suggestible, and her mother asks you what can be done to treat the tics.

How do we treat tics?

Most children will not need treatment, as the tics will typically resolve over time. However, it’s important to educate the child, their family, and their school. This helps foster a positive attitude and promotes greater empathy toward the child.

The main advice is to look positively at tics but to ignore them.

A scoring tool, the Yale Global Tic Severity Scale (YGTSS)1, can used to assess the impact of tics on a child’s daily life and emotional state.

If treatment is needed because it is significantly impacting the quality of life, non-pharmacological approaches such as Behavioural Therapy are the first line. Medical therapy is rare, but in severe cases, patients may require Deep Brain Stimulation via an implant.

You reassure Olivia’s mother that her daughter has simple motor tics that don’t impact her daily life and that there are no other associated conditions requiring treatment.

You advise them to ignore the tics and avoid drawing attention to them. Since the tics are more likely to occur when Olivia is stressed or tired, ensuring she gets adequate sleep and takes breaks from activities can be helpful. You provide the family with resources on managing tics at home and school.

Take home messages

Tics are brief, rapid movements or sounds that the child has an urge to do.

They are associated with other conditions such as OCD, ADHD, depression and anxiety.

Things that look like tics but aren’t include stereotypies, compulsions and functional tics.

The main advice for most children is to ignore them. However, the family and school also need tic education.

Behavioural therapy is the second line. Medication is rarely needed.

References

Tourette syndrome information pack | Great Ormond Street Hospital

Ueda K. Black K. A Comprehensive Review of Tic Disorders in Children. J Clin Med. 2021. 10 (11): 2479. Available at: A Comprehensive Review of Tic Disorders in Children – PMC

 Regiar D. Kuhl E. Kupfer D. The DSM-5: Classification and criteria changes. World Psychiatry. 2013. Available at: The DSM‐5: Classification and criteria changes – Regier – 2013 – World Psychiatry – Wiley Online Library

Szejko N, Robinson S, Hartmann A, Ganos C, Debes NM, Skov L et al. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part I: assessment. Eur Child Adolesc Psychiatry. 2022 Mar;31(3):383-402. Available at: European clinical guidelines for Tourette syndrome and other tic disorders—version 2.0. Part I: assessment

Desai I. Kumar N. Goyal V. An Update on the Diagnosis and Management of Tic Disorders. Ann Indian Acad Neurol. 2023. 26(6): Available at: An Update on the Diagnosis and Management of Tic Disorders – PMC

Lin WD, Tsai FJ, Chou IC. Current understanding of the genetics of tourette syndrome. Biomed J. 2022 Apr;45(2):271-279. Available at: Current understanding of the genetics of tourette syndrome – PMC

 Miller LL. Scharf JM. Mathews CA. Ben-Shlomo Y. Tourette syndrome and chronic tic disorder are associated with lower socio-economic status: findings from the Avon Longitudinal Study of Parents and Children cohort. Dev Med Child Neurol. 2014. Available at: Tourette syndrome and chronic tic disorder are associated with lower socio-economic status: findings from the Avon Longitudinal Study of Parents and Children cohort – PMC

Mathews CA. Scharf JM. Miller LL. Macdonald-Wallis C. Lawlor DA. Ben-Shlomo Y. Association between pre- and perinatal exposures and Tourette syndrome or chronic tic disorder in the ALSPAC cohort. Br J Psychiatry. 2014. 204(1). Available at: Association between pre- and perinatal exposures and Tourette syndrome or chronic tic disorder in the ALSPAC cohort – PMC

Martino D. Schrag A. Anastasiou Z. Apter A. Benaroya-Milstein N.  Buttiglione M. et al. Association of Group A Streptococcus Exposure and Exacerbations of Chronic Tic Disorders: A Multinational Prospective Cohort Study. Neurology. 2021. 96(12). Available at: Association of Group A Streptococcus Exposure and Exacerbations of Chronic Tic Disorders – PMC

Andrén P. Jakubovski E. Murphy TL. Woitecki K. Tarnok Z. Zimmerman-Brenner S. et al. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part II: psychological interventions. Eur Child Adolesc Psychiatry. 2022. 31(3): Available at: European clinical guidelines for Tourette syndrome and other tic disorders—version 2.0. Part II: psychological interventions – PMC

Roessner V. Eichele H. Stern JS. Skov L. Rizzo R. Debes NM. et al. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part III: pharmacological treatment. Eur Child Adolesc Psychiatry. 2022. 31(3): European clinical guidelines for Tourette syndrome and other tic disorders—version 2.0. Part III: pharmacological treatment – PMC