Tics are defined as repeated, sudden, rapid, nonrhythmic muscle movements including sounds or vocalizations. Tourette syndrome is diagnosed when people have had both motor and vocal tics for > 1 year. Diagnosis is clinical. Tics are treated only if they interfere with a child's activities or self-image; treatment may include Comprehensive Behavioral Intervention for Tics and alpha-adrenergic agonists or antipsychotics.
Topic Resources
Tics vary widely in severity; they are common among children, many of whom are not evaluated or diagnosed. Tourette syndrome, the most severe type of tic disorder, occurs in 3 to 9/1000 children (1). Male to female ratio is 3:1 (2, 3, 4).
Tics begin before 18 years of age, typically between 4 years and 6 years of age. They increase in severity to a peak at approximately 10 to 12 years of age and decrease during adolescence (5). Eventually, most tics disappear spontaneously. However, in approximately 1% of children, tics persist into adulthood.
Etiology is not known, but tic disorders tend to be genetic. In some families, they appear in a dominant pattern with incomplete penetrance.
Comorbidities
Comorbidities are common.
Children with tics may have one or more of the following:
These disorders often interfere more with children's development and well-being than the tics do. ADHD is the most common comorbidity, and sometimes tics first appear when children with ADHD are treated with a stimulant; these children probably have an underlying tendency to tics.
Adolescents (and adults) may have
Secondary tics are rare but may result from overuse of stimulant medications and from pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS).
General references
1. Scharf JM, Miller LL, Gauvin CA, Alabiso J, Mathews CA, Ben-Shlomo Y. Population prevalence of Tourette syndrome: a systematic review and meta-analysis. Mov Disord. 2015;30(2):221-228. doi:10.1002/mds.26089
2. Centers for Disease Control and Prevention (CDC). Prevalence of diagnosed Tourette syndrome in persons aged 6-17 years—United States, 2007. MMWR Morb Mortal Wkly Rep. 2009;58(21):581–585.
3. Knight T, Steeves T, Day L, et al. Prevalence of tic disorders: A systematic review and meta-analysis. Pediatr Neurol. 2012;47(2):77–90. doi:10.1016/j.pediatrneurol.2012.05.002
4. Jafari F, Abbasi P, Rahmati M, Hodhodi T, Kazeminia M. Systematic Review and Meta-Analysis of Tourette Syndrome Prevalence; 1986 to 2022. Pediatr Neurol. 2022;137:6-16. doi:10.1016/j.pediatrneurol.2022.08.010
5. Groth C, Mol Debes N, Rask CU, Lange T, Skov L. Course of Tourette Syndrome and Comorbidities in a Large Prospective Clinical Study. J Am Acad Child Adolesc Psychiatry. 2017;56(4):304-312. doi:10.1016/j.jaac.2017.01.010
Classification of Tic Disorders
Primary tic disorders are divided into 3 categories by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) (1):
Provisional tic disorder: Single or multiple motor and/or vocal tics have been present < 1 year.
Persistent tic disorder (chronic tic disorder): Single or multiple motor or vocal tics (but not both motor and vocal) have been present for > 1 year.
Tourette syndrome (Gilles de la Tourette syndrome): Both motor and vocal tics have been present for > 1 year.
These categories typically form a continuum in which patients begin with provisional tic disorder and sometimes go on to persistent tic disorder or Tourette syndrome. In all cases, age at onset must be < 18 years, and the disturbance cannot be due to physiologic effects of a substance (eg, cocaine) or another disorder (eg, Huntington disease, postviral encephalitis). (Substance-induced or other disorder-induced tics are classified as secondary tic disorders and are not included under primary tic disorders in the DSM-5-TR.)
Sometimes children with explosive-onset tics and/or related obsessive compulsiveness have had a streptococcal infection—a phenomenon sometimes called PANDAS. Many investigators do not believe that PANDAS is distinct from the spectrum of tic disorders.
Classification reference
1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, 2022.
Symptoms and Signs of Tic Disorders
Patients tend to manifest the same set of tics at any given time, although tics tend to vary in type, intensity, and frequency over a period of time. They may occur multiple times in an hour, then remit or barely be present for ≥ 3 months. Typically, tics do not occur during sleep.
Tics can be:
Motor and/or vocal
Simple or complex
(See table Types of Tics.)
Simple tics are a very brief movement or vocalization, typically without social meaning (ie, may not be recognizable gestures or words).
Complex tics last longer and may involve a combination of simple tics. Complex tics may appear to have social meaning and thus may seem intentional. However, although some patients can voluntarily suppress their tics for a short time (seconds to minutes) and some notice a premonitory urge to perform the tic, tics are not voluntary and do not represent misbehavior.
Stress and fatigue can make tics worse, but tics are often most prominent when the body is relaxed, as while watching TV. Tics may lessen when patients are engaged in tasks (eg, school or work activities). Tics rarely interfere with motor coordination. Mild tics rarely cause problems, but severe tics, particularly coprolalia (involuntary utterances of obscene or inappropriate words or phrases), are physically and/or socially disabling.
Sometimes tics are explosive in onset, appearing and becoming constant within a day.
Types of Tics
Type | Motor | Vocal |
|---|---|---|
Simple | Blinking Grimacing Head jerking Shoulder shrugging | Grunting or barking Sniffing or snorting Throat clearing |
Complex | Combinations of simple tics (eg, head turning plus shoulder shrugging) Copropraxia: Using sexual or obscene gestures Echopraxia: Imitating someone's movements | Coprolalia: Uttering socially inappropriate words (eg, obscenities, ethnic slurs) or phrases Echolalia: Repeating one's own or another's sounds or words |
Diagnosis of Tic Disorders
History and physical examination
Diagnosis is clinical.
To differentiate Tourette syndrome from transient tics, physicians may have to monitor patients over time. Tourette syndrome is diagnosed when people have had both motor and vocal tics for > 1 year.
Treatment of Tic Disorders
Comprehensive Behavioral Intervention for Tics (CBIT)
Sometimes alpha-adrenergic agonists or antipsychotics
Treatment of comorbidities
Treatment to suppress tics is recommended only if they are significantly interfering with children’s activities or self-image; treatment does not alter the natural history of the disorder. Often, treatment may be avoided if clinicians help children and their families understand the natural history of tics and if school personnel can help classmates understand the disorder.
A type of behavioral therapy called CBIT should be strongly considered and may help some older children control or reduce the number or severity of their tics. It includes cognitive-behavioral therapy such as habit reversal training (learning a new behavior to replace the tic), competition-based techniques to execute a voluntary muscle movement that is incompatible with the presenting tic, education about tics, and relaxation techniques (1).
Sometimes the natural waxing and waning of tics makes it appear that the tics have responded to a particular treatment.
(See also the American Academy of Neurology's review summary of treatment of tics in people with Tourette syndrome and chronic tic disorders [2019].)
Medications
Oral alpha-adrenergic agonists are recommended by the European Society for the Study of Tourette Syndrome and are considered first-line medications for mild to moderate tics in patients with comorbid ADHD (2, 3):
Clonidine is started once daily at bedtime and is increased gradually to the maximum dose, given twice daily, if needed (Clonidine is started once daily at bedtime and is increased gradually to the maximum dose, given twice daily, if needed (3).
Guanfacine is started once daily at bedtime and is increased gradually to the maximum dose, given twice daily, if needed. Guanfacine is started once daily at bedtime and is increased gradually to the maximum dose, given twice daily, if needed.
An adverse effect of clonidine is fatigue, which may limit daytime dosage; hypotension is uncommon.
Oral antipsychotics may be required for symptoms that are more difficult to control and are considered second-line medications because of potential adverse effects. Options include aripiprazole, haloperidol, and pimozide.may be required for symptoms that are more difficult to control and are considered second-line medications because of potential adverse effects. Options include aripiprazole, haloperidol, and pimozide.
Fluphenazine, topiramate, and botulinum toxin injection have also been used as therapy to suppress tics.Fluphenazine, topiramate, and botulinum toxin injection have also been used as therapy to suppress tics.
With any medication, the lowest dose required to make tics tolerable is used; doses are tapered as tics wane. Adverse effects of dysphoria, parkinsonism, akathisia, and tardive dyskinesia are rare but may limit use of antipsychotics; using lower daytime doses and higher bedtime doses may decrease adverse effects. Associated conditions should also be considered when choosing a medication.
Treatment of comorbidities
Treating comorbidities is important.
Comorbid anxiety may be controlled with clonidine and guanfacine.Comorbid anxiety may be controlled with clonidine and guanfacine.
ADHD can sometimes be successfully treated with low doses of stimulants without exacerbating tics, but an alternative treatment (eg, atomoxetine) may be preferable.ADHD can sometimes be successfully treated with low doses of stimulants without exacerbating tics, but an alternative treatment (eg, atomoxetine) may be preferable.
If obsessive or compulsive traits are bothersome, a selective serotonin reuptake inhibitor may be useful.
Children who have tics and who are struggling in school should be evaluated for learning disorders and provided with support as needed.
Treatment references
1. Piacentini J, Woods DW, Scahill L, et al. Behavior therapy for children with Tourette disorder: a randomized controlled trial. JAMA. 2010;303(19):1929-1937. doi:10.1001/jama.2010.607
2. Singer HS. Tics and Tourette Syndrome. Continuum (Minneap Minn). 2019;25(4):936-958. doi:10.1212/CON.0000000000000752
3. Roessner V, Eichele H, Stern JS, et al. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part III: pharmacological treatment. Eur Child Adolesc Psychiatry. 2022;31(3):425-441. doi:10.1007/s00787-021-01899-z
Key Points
Tics are repeated, sudden, rapid, nonrhythmic muscle movements or vocalizations that develop in children < 18 years old.
Tics are common among children.
Coprolalia (involuntary utterances of obscene or inappropriate words or phrases) may be a presenting symptom.
Simple tics are very brief movements and/or vocalizations (eg, head jerk, grunt), typically without social meaning.
Complex tics may appear to have social meaning (ie, be recognizable gestures or words) and thus seem intentional, but they are not.
Strongly consider Comprehensive Behavioral Intervention for Tics (CBIT) as the initial treatment option for tics.
An alpha-adrenergic agonist such as clonidine or guanfacine is beneficial for both mild tics and ADHD.An alpha-adrenergic agonist such as clonidine or guanfacine is beneficial for both mild tics and ADHD.
An antipsychotic may lessen severe or difficult to control tics but may cause adverse effects.
Comorbidities (eg, ADHD, obsessive-compulsive disorder) are common and must also be diagnosed and treated.
