Assessing tics in childrenBMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2021-069346 (Published 03 March 2022) Cite this as: BMJ 2022;376:e069346
- Valsamma Eapen, professor and chair, infant, child and adolescent psychiatry1 2 3,
- Tim Usherwood, Emeritus professor of general practice4 5
- 1University of New South Wales, Sydney, Australia
- 2South Western Sydney Local Health District, Liverpool, Australia
- 3Ingham Institute of Applied Medical Research, Liverpool, Australia
- 4Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- 5The George Institute for Global Health, Sydney, Australia
- Correspondence to V Eapen
What you need to know
Up to 20% of children develop a motor tic as part of their development; most tics last from a few weeks to months
Tourette’s syndrome is characterised by multiple motor and one or more vocal tics lasting for more than one year
Tourette’s syndrome is often associated with comorbidities including obsessive compulsive disorders, obsessive compulsive behaviours, attention deficit/hyperactivity disorder, or autism
Motor and/or vocal tics are relatively common, occurring in about 1% of children of school age. They are also a characteristic of Tourette’s syndrome, a neurodevelopmental disorder in which multiple motor tics and one or more vocal tics have been present for more than a year. Tic disorders are often undiagnosed or misdiagnosed.1 This article outlines a general approach for primary care clinicians to assess a child who has a tic. We highlight the different considerations depending on the age of the child and the presenting symptoms.
Tics vary in type, frequency, and severity over time. They are usually preceded by a premonitory sensation in the form of a stretch/tension or tingling at the site of the tic or a mental urge which is relieved by performing the tic.2 Typically, the relief lasts for a short period and the urge returns. Tics can be voluntarily suppressed for seconds to minutes or several hours (eg, some children may suppress them at school) and this may be followed by a rebound. Frequency of tics is usually reduced when the child is relaxed, focused, or when distracted, such as while playing sports or a musical instrument. Tics are typically made worse by stress, anxiety, lack of sleep, or tiredness.
Parents may seek medical advice if the tics are bothersome, cause unwanted attention or embarrassment because of the frequency, type, site, and nature of tics, or because they are causing pain (eg, because of repeated movements). Parents may also seek advice about the significance or causes of the tics. An initial assessment might aim to:
Distinguish tics from other involuntary movements—(eg, chorea, athetosis, dystonia) or stereotypies. Stereotypies are repetitive purposeless movements such as hand flapping. They can be primary with no underlying condition (often self-limiting or adaptations are made to camouflage the movement) or secondary (eg, restricted repetitive behaviours or self-stimulatory behaviours such as rocking, which are more prevalent in children with autism or a learning disability) (table 1, box ‘Additional resources’)
Assess for comorbidities3—including obsessive compulsive disorder (OCD), obsessive compulsive behaviour (OCB), attention deficit/hyperactivity disorder (ADHD), depression, anxiety, learning disability
Assess for psychosocial issues—consider school functioning, family and friendships, self-esteem, and the impact on quality of life.1
A first presentation of a child with a tic
A 7 year old boy, Tom, is brought to the general practitioner (GP). His mother reports that recently he has had a dry cough and has been twitching his nose. She wonders if this is caused by an allergy. Last year Tom saw an ophthalmologist for excessive blinking but nothing abnormal was found.
Potential diagnoses here include a primary tic disorder (box 1),4 transient developmental tics, mannerisms, or stereotypies. Seek a detailed description of the tic characteristics (table 1) and presence of any previous or current tics or family history. Ask about the type, nature, frequency, intensity, and impact of tics, noting that they can be motor or vocal and may be simple or complex (table 2). Involuntary swearing (coprolalia) is present in 20-30% of people with confirmed Tourette’s syndrome. Depending on the first symptom, families may be concerned about a range of possible causes, including stress, allergies, conditions of the eye, nose, or throat, and more recently covid-19.
Types of primary tic disorders
Transient or provisional tic disorder: tics persisting for less than 12 months
Chronic or persistent tic disorder: multiple motor tics or vocal tics lasting >1 year
Tourette’s syndrome: multiple motor and one or more vocal tics lasting >1 year
Up to 20% of children have motor tics as part of their development, but these usually last for only a few weeks to months.5 In Tom’s case, his parents report excessive blinking (a possible motor tic) a year ago, and now nose twitching, another motor tic, as well as cough, a likely vocal tic, so that a diagnosis of Tourette’s syndrome should be considered. Tourette’s syndrome is three to four times more common in boys; tics typically start at the age of 6-7.6
Tourette’s syndrome is a clinical diagnosis.7 Patients and their families find it helpful to have a clear diagnosis, along with information about the putative cause, likely prognosis, management options,8 and associated comorbidities.9 As the tics are not causing any problems for Tom, no active intervention is needed at present, and the family can be advised that it is best to ignore the tics, as drawing attention to them (including asking Tom to stop) may make symptoms worse. Direct parents and carers to websites that provide accurate and reliable information. Families may also find it helpful to know that many famous and successful people have had Tourette’s syndrome.10
Tics presenting with associated comorbidities
Sam presents with his mum to the GP clinic. His mum says that Sam is having significant problems at school and was recently assessed by the learning support team for poor attention and disruptive behaviours, including pulling faces at the teacher and disturbing the class by making silly noises. Sam also complains that he is not able to do some of the sums in his maths class as he has to convert everything into even numbers because he is not able to work with odd numbers.
In around 90% of people attending specialist clinics, Tourette’s syndrome is associated with comorbid conditions such as ADHD and (less commonly) autism spectrum disorder (ASD).6 It is also associated with OCD and OCB (eg, obsession with specific numbers or symmetry, “evening up” behaviours such as action on one side and then the other to make it “even,” or doing things until it feels “just right” that are commonly associated with tics but often do not reach the threshold of clinical disorder diagnosis because of not fulfilling the distress and dysfunction criteria). Ask about tics and these comorbid conditions in the patient and in family members.11 Certain genes have been implicated in Tourette’s syndrome and in its links to ADHD and OCD.12
People with Tourette’s syndrome may also have anxiety, depression, problems with sleep, self-injurious behaviours, anger or rage, poor impulse control and behavioural disinhibition, disruptive disorders, and learning disorders (fig 1).5 When behavioural or mental health difficulties are the presenting complaints, tics may be missed. In Sam’s case, at times the comorbidities are more problematic and will need more intervention than tics themselves.13
Initial management and referral
Figure 2 details the general principles for managing tics. Provide information and resources to parents and school, explaining that tics are outside the child’s control. Box 2 offers some helpful strategies to minimise the negative effects of tics on a young person’s life. Simple tics causing no distress or dysfunction might benefit from watchful waiting, but if pain (caused by repeated movements), distress, or dysfunction occurs, empirically supported drug14 and behavioural interventions15 are available.16 Consider referring to a specialist (eg, paediatrician, child psychiatrist) if the patient has symptoms, whether from comorbidities or from tics, that remain problematic despite initial management. Refer to a neurologist for sudden-onset chorea, ataxia, or dystonia; to a mental health specialist for comorbidities including anxiety, mood, or obsessive compulsive disorder; or to a neurodevelopmental specialist for ADHD or autism.
Strategies to help young people with tic disorders
Psychoeducation of young person, family, teachers and peers
Provide proactive (not reactive) support and predictable routines
Provide breaks, with opportunities for physical movement
Designate a safe place to go to when tics are severe, with a pre-agreed pass or signal for time out
Preferential seating (eg, front of the class, close to the door)
A buddy for learning and social support (may help prevent bullying)
Planning/managing communication about tics (to school, peers/friends, employer) and self-advocacy (how to respond if asked about tics)
Allow scribe/computer if writing is affected; special provisions for examinations—seating in a separate room, allowing extra time
Identify and avoid triggers; manage stress, anxiety, or boredom
Encourage relaxing activities and foster strengths and hobbies to boost self-esteem
Join support groups to share experiences and attend activities or events such as camps
Living with Tourette’s syndrome
My first memory of a tic was repeated grunting in my primary school classroom, much to the irritation of my teacher and amusement of my classmates. Some weeks later, I saw my father wrinkle up his nose in response to an unpleasant smell. My grunting gave way to nose wrinkling. Over subsequent months and years, I acquired new tics and lost earlier ones. They became more complex, often combining grunting with other movements, and mainly affecting my face, neck, shoulders, and arms. Inevitably, my nickname at school was “Twitch.” Although I saw several doctors and a child psychologist, my condition remained undiagnosed until I was at university. In my third year of medicine, I asked our psychiatry lecturer if he could explain the cause of my tics. He referred me to a neurologist, and it was an enormous relief when I received a diagnosis of Tourette’s syndrome. At last I had a reason, and a way of talking about my symptoms.
After a brief and unsuccessful trial of medication, I learned to live with Tourette’s syndrome. At times the tics are socially embarrassing, but they have also been the source of shared amusement. I have never experienced coprolalia but I am aware of a temptation to copy the verbal and non-verbal tics of others. Occasionally, I have left the room to avoid “catching” a tic. I am now 68. My tendency to tic has reduced markedly over the last decade or so, but is still present when I feel stressed. Fatigue, study, and mental concentration can exacerbate their frequency. Listening to music and taking part in physical activity both reduce the urge. The tics are part of who I am—not particularly welcome—but as much a part of my makeup as my eye colour.
Tourette Syndrome Association of America. https://tourette.org/resources/tourette-resources/
Tourettes Action UK. https://www.tourettes-action.org.uk/8-find-support.html
Tourette Syndrome Association of Australia. https://tourette.org.au/services/information-support/
Child and Parent Research Institute, Ontario. https://leakybrakes.ca/brake-shop/brake-shop-clinic-resources/
National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/ng127/chapter/recommendations-for-children-aged-under-16#tics-and-involuntary-movements-in-children - NICE Guidelines
UK NHS Consumer page. https://www.nhs.uk/conditions/tourettes-syndrome/
Education into practice
What advice and resources might you offer Sam and his parents on first presentation?
How would you screen for comorbidities in a patient with possible Tourette’s syndrome?
Who among your patients has possible or confirmed Tourette’s syndrome? Based on this article, what changes to their management might you offer?
How this article was created
VE developed one of the case vignettes to illustrate early symptom presentation and the subsequent development of comorbidities, based on an anonymised case from clinical practice. TU provided a personal account.
How patients were involved in the creation of this article
TU has lived with Tourette’s syndrome for more than 60 years. The manuscript was discussed with executives from the Tourette Syndrome Association Australia and in particular Robyn Latimer (RL), who reviewed the manuscript and whose views helped shape the section on management strategies to assist young people with tics.
Competing interests: none.
Contributorship and the guarantor: VE and TU conceived the article and are guarantors. VE drafted the article; TU and VE reviewed and further edited the draft. Further input was received from Tourette Syndrome Association Australia.
We thank Robyn Latimer for reviewing a draft of the article.