Tic Disorders in Children

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Tics are quick, repetitive movements of any part of the body including the mouth and vocal cords. They are often described by people as “relatively involuntary” because these movements can often be suppressed but not indefinitely. Often people will feel the tic coming and be able to suppress it temporarily. Most of the time there is a physical or mental urge to complete the tic before it occurs. Tics usually first appear in the face, but not always. They often migrate and spread to other parts of the body and may come and go over time depending on physical and emotional stress.

There are 2 types of tics which can be classified into 4 main disorders. The two types of tics are simple and complex. Simple tics involve one or a few muscle groups and are very brief. Examples of simple tics include eye blinking, shoulder shrugging, grunting, throat clearing, etc. Complex tics, on the other hand, are much more integrated actions. These involve multiple muscle groups and can be very elaborate and in many cases extremely disruptive.

Tics that occur regularly for more than four weeks and up to one year fall into the type of disorder classified as transient tic disorder. Once tics have occurred persistently for one year we further classify the disorder as chronic motor tic disorder, chronic vocal tic disorder or Tourette’s disorder (also known as Tourette Syndrome). As the names suggest, chronic motor tic disorder involves only motor tics (ex: twitching, eye blinking, head bobbing, shoulder shrugging), and chronic vocal tic disorder includes purely vocal tics (ex: grunting, coughing, throat clearing). Vocal tics can also include more complex sounds such as yelling bad words (coprolalia), repeating words (echolalia), or randomly saying nonsense words (palilalia). However, these are much less common. Tourette’s disorder (which I will now call TD) by definition requires at minimum one year of both vocal and motor tics, although the vocal and motor tics do not need to be present at the same exact time.

Tic disorders usually begin between the ages of 2 and 15 years old. The average age when they begin is around 6 years of age. Often symptoms will worsen until around age 10 and then gradually improve. Usually symptoms improve a lot during adolescence. Sometimes, however, symptoms continue into adulthood and are much more chronic. We are not completely sure why, but boys are 3 times more likely to have a tic disorder than girls. Overall, TD affects about 1% of the population at any point in their lives. Studies have definitely shown that tic disorders can run in families and have a genetic component. But, other factors such as anxiety, premature birth, infections, and head injuries can also play a role in the development of tic disorders.

People who develop tic disorders are also at higher risk for other psychiatric conditions. Attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) are commonly diagnosed in people who have tic disorders. People with tic disorders are also more likely to have other anxiety disorders, aggressive behaviors, temper outbursts and social struggles. They may also be more prone to developing mood disorders such as depression if they experience bullying or shunning by peers. Occasionally, tic disorders occur suddenly after a bacterial infection. This is rare and controversial, but when it occurs there is typically a quick onset of tics, obsessions and compulsions following a streptococcal infection and is known as Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). Symptoms usually go away with antibiotic treatment for the underlying bacterial infection.

Management of tic disorders can depend a lot on how severe and disruptive the tics are for a person and the family. The goal of treatment for tic disorders is just to reduce the frequency or disruption of tics. Typically the only thing that really takes tics completely away is time. One treatment option is psychotherapy or talk therapy. Talk therapy is usually helpful for many reasons. Sometimes talking about the tics helps suppress the urge to tic. Keeping a log of things that make tics worse or better and discussing this with a therapist can be helpful in managing those things that worsen the tics and encouraging behaviors or activities that make them better. For people who experience urges to complete a tic, a form of therapy called cognitive behavioral therapy can help a person with a tic disorder manage how they respond to the urge to tic and think of alternative behaviors to reduce embarrassing or disruptive tics.

If the tics are disruptive to a person’s life and/or cause social issues, medications may be helpful. Two main classes of medications have been shown to be effective in making tics less frequent and less disruptive. Both types of medications have side effects and as always should be carefully considered with a physician before starting. The first type of medications is known as the antipsychotic medications, although we use them for more than just treating psychosis. These medications act on a chemical in the brain called dopamine. One particular drug in that class of medications, called pimozide, has been studied with positive results in tic disorders and has been given FDA approval for use in patients with TD. Examples of other antipsychotic drugs include risperidone and haloperidol. Another class of medications that we use is called the alpha-2 adrenergic agonists, which includes a drug called clonidine. These medications also affect dopamine in the brain but through a slightly different pathway. It’s important to talk with your physician about the risks and benefits of all treatments before starting a new medication.

The Tourette Syndrome Association has national and local chapters available and is a good resource for patients and families struggling with TD. For more information visit http://www.tsa-usa.org/index.html.


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