What are tics?
Tics are involuntary movements or vocal sounds made by children repeatedly. Commonly they are eye blinking or throat clearing.
What types are there?
Simple motor tics - The most common. They involve only one muscle group. Examples are eye blinking, lip pouting, facial grimacing, and arm jerking.
Simple vocal tics – They involve only one sound. Examples are sniffing, grunting or throat clearing.
Complex motor tics – They involve more than one muscle group. Examples are headbanging or skin picking.
Complex vocal tics – They can be part of normal words, whole words or phrases. Examples include the use of swear words (coprolalia - popularised in movies and television (1)).
Is Tourette Syndrome the same as a tic disorder?
The formal definition of Tourette syndrome is the presence of vocal and motor tics for longer than a year. You can just have tics without fulfilling the criteria for a diagnosis of Tourette syndrome.
Tourette syndrome is often inaccurately and negatively portrayed in the media (1), which can lead to anxiety. If you are concerned about this diagnosis, then seek medical advice that is accurate for your child in your child’s situation, to give you more individualised and accurate information.
How common are tics?
Tics in children are common, reported in up to 20%. Conventional wisdom was that tics would disappear within a few months, and many children outgrow them by puberty. A recent article (2) reports that it is not uncommon for tics to be present for up to a year, though they may not be as obvious or distressing at this time giving the impression they have gone.
If tics were present for longer than a year, they are considered as chronic motor tic disorder and if there are vocal and motor tics present Tourette syndrome is the classification used, with these being considered as two distinct entities. A recent review suggests that we should re-frame this view and see that tic disorders lie on a spectrum of severity, not as distinct entities (3).
What other conditions are associated with tics?
There are many conditions that can occur at the same time as tics, otherwise classified as co-morbidities. They include anxiety, obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD) and learning disabilities. However, tics can occur in isolation, and if they do, they are more likely to disappear over time.
It is useful to consider these associations in a child who presents with tics to help make a management plan for them. Sometimes the plan is to watch and wait.
How are tics treated?
The usual management strategy for tics is to ignore them, reduce the attention paid to them, and they will usually go away. When drawing attention to tics they can increase even though they are involuntary. When starting to ignore tics there can also be an increase in frequency sometimes referred to as an extinction burst. Reducing tiredness and stress can help to reduce tics as these factors are noted to contribute to increased tic frequency.
Treating the underlying conditions or co-morbidities can help alleviate the frequency and severity of tics. However, if the tics persist or are causing significant distress, then medication to suppress the tics may be trialled. That is uncommon in children.
Can my child’s ADHD medication cause tics?
For over 20 years there has been a concern about the role of stimulant medication and tics. With more up to date understanding, investigation and review (4), it has been shown that the two conditions (tics and ADHD) co-exist, and that the medication does not cause the tics. Some children’s tics reduce with the management of their ADHD symptoms using stimulants, however, there does seem to be a minority of cases where tics worsen with their use.
So, as is always the case, it is a matter of seeing the child, assessing them and their symptoms on their merits and treating accordingly. If the tics seem to increase with stimulant medication, then other alternatives can be considered when the role of tiredness, stress and anxiety have also been addressed. This highlights individualised medicine, not treating the studies, but treating the individual.
So, in summary?
Tics are common in children and many disappear by puberty. Tics are commonly associated with other conditions such as ADHD, though stimulant medication does not seem to cause them.
References:
1. Calder-Sprackman, S., Sutherland, S., & Doja, A. (2014). The Portrayal of Tourette Syndrome in Film and Television. Canadian Journal of Neurological Sciences / Journal Canadien Des Sciences Neurologiques, 41(2), 226-232.
2. Kim, S., Greene, D.J., Bihun, E.C. et al. Provisional Tic Disorder is not so transient. Sci Rep 9, 3951 (2019).
3. Müller-Vahl, K.R., Sambrani, T. & Jakubovski, E. Tic disorders revisited: introduction of the term “tic spectrum disorders”. Eur Child Adolesc Psychiatry 28, 1129–1135 (2019).
4. Graham, J., Coghill, D. Adverse Effects of Pharmacotherapies for Attention-Deficit Hyperactivity Disorder. CNS Drugs 22, 213–237 (2008).