Tics, which represent involuntary repetitive motor movements and/or vocalisations, are extremely common in children. They occur predominantly in the first decade of life, are more common in boys, and generally last from 1 week to 1 year. Blinking, throat clearing and facial movements are the most common tics.
Tourette syndrome (or Gilles de la Tourette syndrome) is diagnosed when there have been 2 or more motor and 1 or more vocal tics (not necessarily concurrently) present for more than 12 months, with no tic free period for more than 3 months. It is also more common in males in the first decade of life.
Tics and Tourette syndrome are clinical diagnoses, usually quite easy to diagnose on history alone. It remains important to ensure a normal examination.
Differentials
Seizures are distinguished from simple tics in that the latter are repetitive and periodic, as well as often being distractible or suppressible. There is no altered consciousness during tics.
Other neurological diagnoses can present with or mimic tics, thus a thorough history and examination focussing on neurology is required.
Mental health disorders are often seen in association with Tourette syndrome and tics, including anxiety and OCD (see mood disorders), autism spectrum disorders, learning disorders, ADHD and behavioural difficulties (e.g. ODD). It is very important to screen for these co-morbidities.
- Tics and Tourette syndrome are clinical diagnoses, usually quite easy to diagnose on history alone, with investigations generally not required.
- Management is often not required for simple tics - reassurance and education are sufficient.
- Treatment is generally reserved for those children in whom the tics have become functionally impairing. It is important not to treat the parental anxiety, as it is often more of a concern for the family than the child themselves!
- Diagnosis or management of simple tics can generally be undertaken in the general practice setting, without need for paediatric input.
Investigations are generally not required for the diagnosis of tics or Tourette syndrome.
Management is often not required for simple tics, with most children generally stopping them within 12 months, although is it quite common to see a child transition through multiple different tics before they cease. Reassurance and education remain the mainstay.
Treatment is generally reserved for those children in whom the tics have become functionally impairing. It is important not to treat the parental anxiety, as it is often more of a concern for the family than the child themselves! Options include:
- psychological therapies:
- CBT
- certain specific behavioural therapies
- medical therapies:
- clonidine, SSRIs, atypical antipsychotics and some others (about 50% efficacy)
- typical antipsychotics (about 80% efficacy, although treatment limiting side effects common)
- Paediatrician
- Diagnosis or management of simple tics can generally be undertaken in the general practice setting, without need for paediatric input.
- Referral to paediatric outpatient services can be considered in the management of tics when there is functional impairment, or if Tourette syndrome is present. Also consider co-morbidities.
- Psychologist
- Mental health services may be useful for psychological therapies for more troublesome tics.
- Neurologist
- Very few children with tics or Tourette syndrome ever need to see a neurologist - this could be considered if there is ongoing functional impairment despite failure of psychological and medical therapies.