Tics

Introduction

Tics are sudden, repetitive muscle movements or vocalisations that are difficult to control. The cause is not known, but complex genetic (inherited) and neurobiological factors are involved. They are relatively common in childhood, typically beginning around 5 years of age. For many children, tics increase during adolescence but improve over time. Approximately 50% of children with tics will experience full remission by adulthood, and most of the remainder will experience them less frequently than in childhood.

Tics typically wax and wane over time. Tics are not behavioural or voluntary. Some children may be able to partially suppress tics temporarily but this commonly results in increased tics later on. Drawing attention to them can make them worse. Most people with tics require no specific therapy.

Tics can affect any part of the body. Motor tics commonly involve the face initially, such as eye blinking, but may later spread to the neck, arms or legs. Motor tics occur in up to 20% of children as a developmental phase, but do not usually last longer than one year, and are often not problematic.

Vocal tics may start as simple sounds (e.g. sniffing, throat clearing) and may later become more complex (e.g. words or short phrases). The progression and presentation of tics can vary between individuals.

Tourette's syndrome occurs in about 1% of school aged children characterised by both multiple motor tics plus at least one vocal tic that cannot easily be controlled, and lasting more than one year. It often has a genetic basis and may run in families. Most people can identify someone in their extended family with tics or obsessive-compulsive disorder (OCD). Some children with Tourette's syndrome may have co-existing conditions such as OCD, attention deficit hyperactivity disorder (ADHD) or anxiety. Tics typically start around 6-7 years, with peak severity at around 10-12 years, and typically improve by adolescence or thereafter.

Types of tics

Pre-referral investigations

• Clinical history including:
  • Onset, duration, frequency and impact of tics
  • Most distressing or impairing symptoms
  • Potential triggers or exacerbating factors (e.g. stress, fatigue)
  • Developmental and psychosocial history
  • Family history of tics, OCD, ADHD or other neurological/psychiatric conditions
• Assessment for comorbidities (e.g. ADHD, OCD, anxiety, mood disorders, learning difficulties)
• Family and school functioning
• Physical and neurological examination
• Neuroimaging or EEG (only if indicated e.g. atypical features, regression, seizures or abnormal neurological signs – not specifically required for isolated tics) 

Pre-referral management  

Most people with tics require no specific therapy. Tics in themselves are not harmful but some children experience difficulty concentrating, fidgeting, impulsivity or anxiety. There is no cure for tics, but supportive management and increased understanding can help children and families.

• Education and reassurance: normalise the condition where appropriate and discuss typical progression. Active ignoring is known to be helpful as tics can worsen when attention is drawn to them.
• Lifestyle: promote regular sleep and physical activity, stress management and confidence. Helping patients to feel good about themselves can help them cope with times when symptoms might be uncontrolled. Mindfulness can be helpful.
• School strategies: provide supportive strategies for the classroom if tics are interfering with learning or peer relationships (active ignoring, address teasing etc)
• Behavioural therapy: in motivated older children with moderately severe tics, behavioural approaches such as cognitive behavioural therapy may be appropriate. GPs can refer to a clinical psychologist under a mental health care plan.
• Medication: may be considered if tics are severe and significantly impacting quality of life such as causing pain. Choice of medication should be individualised and made in consultation with families. Different types of medication may need to be tried under the supervision of a clinician. Medication does not treat the underlying cause of tics but can treat some of the symptoms. First line therapy is usually clonidine. It is important to monitor blood pressure as these agents can cause hypotension. If ceased abruptly they can also cause rebound hypertension.

When to refer

How to refer

• Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service.
• Routine non-urgent referrals from private hospitals go to the PCH Referral Office (Fax: 6456 0097 or email).
• Urgent referrals (less than 7 days) go to the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 222 to discuss referral with the General Paediatrician on-call.

Essential information to include in your referral

• Detailed description of tics and progression
• Impact on daily function, education, and social life
• Concerning features e.g. neurological findings
• Treatments trialled
• Developmental and family history
• Results of physical and neurological examinations
• Any investigations performed and results

References

1. European clinical guidelines for Tourette syndrome and other tic disorders—version 2.0. Part I: assessment | SpringerLink (health.wa.gov.au)
2. Diagnostic approach to paediatric movement disorders: a clinical practice guide - Brandsma - 2021 - Developmental Medicine & Child Neurology - Wiley Online Library
3. Hyperkinetic movement disorders in children - UpToDate (health.wa.gov.au)
4. Tourette Syndrome in children. Australian Journal of General Practice Vol 50 (3), March 2021

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