Tics in childhood and adolescence – how to tell apart repetitive behaviors?

Everyone has heard of Tourette’s Syndrome, and for the most part, he thinks he knows what it is: weirdos swearing loudly and uncontrollably in normal situations. Well, the description of the tic disorders in the vast majority of real cases could not be further from that assumption. Since one in 162 children is affected and in most cases we probably don’t even know, we found it timely to gather what you need to know about this disorder.

Tic disorder, also known as Tourette’s syndrome, is surprisingly common and, in the rarest of cases, involves uncontrolled swearing. These are usually short patterns of behavior with one or few elements of movement and / or sound that are repetitive. Symptoms appear in early childhood or adolescence, between 2 and 15 years of age. The criterion for this diagnosis is that the tic phenomenon that has existed for more than a year. There are movement-type and vocal type of tics which can appear together. The movement tics can be the following: involuntary movements on the face, arms, limbs, or just the torso. These tics are common, recurrent, and rapid. The most common ones appear on the face: blinking, nasal twitching, eyebrow twitching and other small grimaces with interesting facial muscle movements. These movements, which are quasi-uncontrollable by the child or young person, can in some cases be whole-body, complex sequences of movements: kicking, pounding, touching, and even recurring thoughts and compulsions. Sound or vocal tic can be, for example, growling, throat grinding, coughing, shouting, barking, but it also includes the much-mentioned coprolalia, which manifests itself in involuntary swearing. It is important to note that neither coprolalia nor echolalia (mimicking the speech of others) are among the most common signs of Tourette’s syndrome and therefore not a condition for diagnosis!

Assessment of the disorder:

• The psychiatric assessment should involve routine screening for unusual movements, stereotypies, tics, and family history of tic disorders. Careful examination of the, and characteristics (like timing and triggers) of the tics may help differentiate tics from another medical problem. Tics usually don’t happen during sleep or in the state of sexual arousal and are usually triggered by stress, mental and physical pressure, and in exciting or uncomfortable situations.
• If the clinician is unsure, checking in to a pediatric specialist (allergist, pulmonologist, and ophthalmologist) is highly recommended. The most commonly used parent-rated behavioural screening tool is the Child Behaviour Checklist (CBCL, or the “Achenbach-test”) include tic-specific questions.
• If the screening is positive or the clinician observes tics during the evaluation, a more systematic assessment for tics will be needed, including the age of onset, types of tics, tic frequency, alleviating and aggravating factors, and a family history of tics. Rating scales specifically for tics may be used in order to determine severity.
• Looking for comorbidities: tic disorders are often coupled with other conditions: 63% had ADHD, 33% had OCD, 49% had anxiety problems, 25% had depression. 35% had autism spectrum disorder, 29% had speech or language problems, 30% had developmental delays, and so on.

Therapy

Psychoeducation should be provided to the youth and family regarding tics including common symptom presentations, risks related to co-occurring conditions, the typical course across the lifetime, prognosis (approximately 25% of the tics go into adulthood), and treatment options. Typical exacerbating factors (e.g., illness, stress, heat, harassment, social situations) and alleviating factors (e.g., relaxation, listening to music, quiet location, reassuring personal presence) should be carefully examined. Banning, scolding and negative reactions to tic is terribly harmful! In many cases, in addition to the enlightened and supportive behaviour of the family, group therapies can also help a lot.

It is important for parents to report the diagnosis at school and be sure to provide school staff with specialist information on tic disorders! In some cases, an individualized education plan may also be required. In rare cases, medication may be required, especially in the presence of other diseases, the efficacy of which is being studied more and more.

Tics are definitely somehow reacted to by the person’s environment. Let’s work together to make this reaction as good as possible for the child or adolescent involved!

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References:

1. Vadaskert: Tic-zavarok, Tourette-szindróma
2. Practice parameter for the assessment and treatment of children and adolescents with tic disorders
3. Somatic cough syndrome and tic cough in adults and children: CHEST guideline and Expert Panel report
4. Centers for Disease Control and prevention: Data & Statistics on Tourette Syndrome