Tic Disorder in Children

What is Tic Disorder?

The frequency, intensity, and type of tics can vary from child to child and are divided into two categories:

• Motor Tics - Usually involve rapid, sudden movements, such as eye blinking, facial grimaces, head jerking, or neck stretching.
• Vocal Tics - Typically manifest as throat clearing, coughing, humming, or grunting noises.

Tic Disorder belongs to a group of neuropsychiatric disorders that typically begin in childhood or adolescence and tend to diminish as the individual grows older. Although tics are often involuntary, they can sometimes be suppressed for a short period. The American classification distinguishes several types of Tic Disorder, including transient tics, chronic motor or vocal tics, non-specific tics, and Gilles de la Tourette syndrome, which is the most severe form. Motor and vocal tics can further be categorized as simple or complex. Complex motor tics may involve behaviors such as self-grooming, jumping, touching, mimicking others, or even inappropriate gestures (copropraxia). Complex vocal tics may include uttering words or phrases unrelated to the conversation context, repeating one's own or others' words, or coprolalia, which involves involuntary swearing or offensive language.

Gilles de la Tourette Syndrome

The prevalence of Gilles de la Tourette syndrome is approximately 0.05% in the child population. It is more common in boys than girls (almost three times more common), with motor tics typically appearing around the age of 7 and vocal tics around the age of 11. The earliest reported age of tic onset in the literature is two years. There is a strong genetic predisposition for the development of this syndrome, although in some cases, streptococcal infections are associated with both the onset of tics and obsessive-compulsive disorder.

Diagnosis of Tourette's Syndrome

According to the American classification (DSM-V), the following criteria must be met for a diagnosis of Tourette's Syndrome:

• The presence of multiple motor tics and at least one vocal tic, not necessarily occurring simultaneously.
• Tics occur on most days for at least one year, with tic-free periods lasting no more than three consecutive months.
• Onset of tics before the age of 18.
• Tics are not attributable to a substance or another medical condition.

Clinical Presentation of Tourette's Syndrome

The clinical presentation can vary widely. Tics can occur in different areas of the body, including the head, neck, upper limbs, trunk, lower limbs, respiratory, and digestive systems. Before the onset of the disorder, individuals may experience increased irritability, attention and concentration difficulties, and low frustration tolerance. Tics often begin with simple motor tics like eye blinking and then progress to more complex tics involving facial contortions. Complex motor tics may include behaviors related to self-care, such as grooming, as well as jumping, touching, mimicking others, or even inappropriate gestures. Complex vocal tics may involve uttering unrelated words or phrases, repeating one's own or others' words, or coprolalia.
Impulsivity, attention and concentration problems, social difficulties, compulsivity, and personality issues can sometimes accompany Tourette's Syndrome. In some cases, tics can lead to aggressive or sexually inappropriate behavior, making it challenging to cope with the disorder.
In most cases, there is an improvement towards adolescence. During childhood, tics may change in terms of intensity, location, and type, often replacing one tic with another. There can be periods of calm with the complete disappearance of tics and periods of exacerbation. Stress and anxiety can exacerbate tics. Most children with mild Tourette's Syndrome do not experience significant difficulties, whether socially, academically, or functionally, and do not require any treatment.

Treatment of Tourette's Syndrome

If treatment is necessary, it is essential to provide an explanation of the course of the disorder. It is crucial to understand that children do not intentionally produce tics, and tics are typically uncontrollable. There are several behavioral techniques based on Habit Reversal Treatment that can help identify the initial sensation or urge that precedes the tic and replace it with a desirable movement. Relaxation and stress reduction techniques can also be helpful. Medication therapy can significantly reduce the intensity and frequency of tics or even eliminate them. Medications typically used include antipsychotics (such as Risperidone, Haloperidol, and Pimozide) and alpha-2 adrenergic agonists (such as Clonidine and Guanfacine) to control tics. For symptoms of compulsivity, selective serotonin reuptake inhibitors (SSRIs) are used. For ADHD symptoms, stimulants can be used with careful monitoring of tic severity.

Chronic Motor and Vocal Tics

Chronic tics are relatively common, affecting 1% to 2% of children in school-age. There is a strong genetic predisposition to the development of this disorder. Motor tics are more prevalent than vocal tics, and there is no history of both motor and vocal tics occurring simultaneously, unlike in Tourette's Syndrome.

Diagnosis of Chronic Tics and Symptoms

The official criteria for the diagnosis of chronic tics are as follows:

• Tics begin before the age of 18.
• Tics have been present for a minimum of four months but not more than one year.
• Tics are not attributed to another medical condition (neurological or movement disorder) or substances (e.g., medications or drugs).

Prognosis and Treatment for Chronic Tics

Symptoms typically persist for 4-6 years and then spontaneously disappear. The prognosis is less favorable when tics involve the arms and body and better when only facial muscles are affected. Treatment for chronic tics is similar to that of Tourette's Syndrome.

Transient Tics

Between 5% and 25% of school-age children experience transient tics.

Diagnosis of Transient Tics and Symptoms

Transient tics are diagnosed if the following criteria are met:

• Tics last for at least four months but not more than one year.
• Tics begin before the age of 18.
• Motor and vocal tics occur separately.
• Tics are not attributed to another medical condition (neurological or movement disorder) or substances (e.g., medications or drugs).

Treatment for Transient Tics

The decision to treat transient tics depends on their severity. If tics significantly affect academic performance, social functioning, or mood, treatment may be considered. The treatment approach is similar to that of Tourette's Syndrome.