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Tics: Primary Steps for Primary Care

Boy holding head

Tics are repetitive, stereotyped, involuntary movements that usually begin in childhood. They can consist of motor and vocal tics, such as excessive eye blinking/rolling, facial grimacing, neck or shoulder jerks, sniffing, throat clearing or other vocalizations. Tics can be transient or chronic.

If chronic, it may meet the criteria for Tourette syndrome. Tourette syndrome is defined as multiple motor and vocal tics that have been occurring for at least one year without more than a three-month tic-free period and diagnosed before the age of 18 years.

Tics have a waxing and waning course, which is many times exacerbated by stress, anxiety, emotional changes or fatigue. The frequency of a tic is often highest after it first arises and decreases over the following weeks, thus often tics will improve with time alone. Onset of tics can be as early as 4-6 years of age, with increasing severity during pre-puberty and puberty ages. The estimated prevalence for tics in childhood is 6-12%.

What are common comorbid conditions of tic disorders?

  • Attention deficit hyperactivity disorder
  • Obsessive compulsive symptoms/disorder
  • Anxiety and depression
  • Learning disorders
  • Sleep disorders

These comorbidities can sometimes provide the biggest impairment and may exacerbate tics as a result.  Most of the time, tics themselves do not require management with medication, but treating these comorbid conditions may be warranted. There are some medications, for example stimulant medications, that have been reported to exacerbate tics. However, randomized controlled trials suggest that stimulants, such as methylphenidate, do not cause exacerbations more than placebo or other medications. 

When should we think about treating tics?

The most important question to consider when deciding to treat tics is, “Do the tics bother the child?” Tics may often concern parents or teachers, but if the child is not adversely impacted by the tics, treatment may not be needed.

Questions to consider:

  • Is the tic causing pain?
  • Is it affecting or disrupting daily activities of living?
  • Is it causing psychosocial stressors to the child? Are others bullying/picking on the child?

What treatment options are there?

With any treatment option, the goal is reduction in tics to a manageable level, not complete tic suppression.  

  • The most important treatment is often education of the family, the patient and/or peers the overall benign nature of tics, the typical waxing/waning frequency and the overall favorable prognosis.
  • Behavioral approaches, such as biofeedback, comprehensive behavioral intervention for tics (CBIT), habit reversal and awareness training, can be beneficial if the child is aware of the tics and desires to gain better control of them.
  • Medication management, such as clonidine, guanfacine, topiramate and anti-psychotics, can be considered. Guanfacine and clonidine may be good choices if the child has comorbid ADHD.
  • In severe cases, more invasive options, such as botulinum toxin, deep brain stimulation and repetitive transcranial magnetic stimulation, may be considered.

When evaluating and treating a child with tics, here’s what may warrant additional investigation or referral:

  • Is there only one type of motor tic, such as eye rolling/fluttering or shoulder jerking, that could be similar to seizure activity? If so, consider obtaining an EEG.
  • Are the associated comorbidities more disruptive to the child and making the tics worse? If so, consider psychiatric referral for evaluation.
  • If tics have not responded to initial treatment approaches or medications noted above.

Cook Children's expertise:

Great outcomes begin with great input. Having a medical system where every department, doctor, and care team member works together means that your child can have quick access to testing, diagnosis and treatment, and that means better outcomes now and in the future. If you would like to schedule an appointment, refer a patient or speak to our staff regarding your child's tics, please call our offices at 682-885-2500.