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TICS are…

 

  • Sudden, rapid (rarely last more than a second), motor movements or vocalizations. They are repetitive and do not have a rhythm.

 

  • Motor tics appear like “fragments of normal movement”. Some are simple (eye blinking, nose twitching, head or arm jerks, shoulder shrugs) while sometimes can be complex (appear to have a purpose, facial or hand gestures).

 

  • Vocal tics can be simple such as throat clearing, coughing, sniffing, spitting, or grunting or complex from sounds, syllables, words, with or without sense. Examples of complex vocal tics are repeating one’s own words (palalalia) or those of others (echolalia) or the urge to say obscenities (coprolalia).

 

  • Often, especially after the age of ten patients with tics describe having premonitory urges similar to the sensation preceding a sneeze or an itch. After the tics have occurred there is often a fleeting sense of relief. For periods of time the patient can suppress the tics but this is difficult, even exhausting. Sooner or later the tics need to be allowed to reduce the distress.

 

Diagnoses

 

In order to diagnose a tic disorder, the tics need to occur many times a day, nearly every day. Most often the onset is before age 18.

Transient Tic Disorder

The tics (motor and/or vocal) are present for more than 4 weeks, but less than 12 months.

Chronic Motor or Vocal Tic Disorder

The tics (motor OR vocal) are present for more than 12 months.

Tourette’s Disorder (or Syndrome)

The tics (motor AND vocal) are present for more than 12 months.

 

Parents report 4–24% of the school-age children to be experiencing tics but much fewer ever get diagnosed with a tic disorder. About 4.5% of children likely have transient tics and 0.7%-1% have chronic tics.

If one of the parents has Tourette’s the risk for the child is 15% to have Tourette’s, 30-29% to have a tic disorder and 12-32% to develop OCD. The risk is higher for boys.

 

 

Clinical Course

 

  • First symptoms start as early as the age 5–7 with simple, transient motor tics: often eye blinking. The tics over time may progress to affect the face, head, neck, arms and the lower extremities.

 

  • The vocal tics tend to occur several years later (8–15 years of age).

 

  • Tic complexity also evolves with age, from single, rapid motor tics towards stereotyped, complex movements and from nonsense sounds developing into elaborate words and phrases.

 

  • By the age of 10 or 11 the child starts to experience premonitory urges: feelings of tightness, tension, or itching that are accompanied by a mounting sense of discomfort that can be relieved only by the tic.

 

  • The premonitory urges offer the child a degree of awareness and warning and some capacity for  voluntary control is developing.

 

  • The voluntary control works only for a limited period of time and only with mounting discomfort, mental and physical exhaustion that can be even more impairing and distracting than the tics themselves.

 

 

Tic severity…

  • waxes and wanes throughout the course of the disorder (hour to hour, week to week, month to month and even year to year).

 

  • Tics tend to get worse in conditions of stress, fatigue and overstimulation.

 

  • Tics tend to be less visible when the child is performing intentional movements and during periods of intense involvement and concentration in activities.

 

  • Most Tourette’s cases are diagnosed by age 11-12, and tend to improve during the adolescence and progressively in the early 20s.

 

  • 50-66% of individuals experience a marked reduction of symptoms by their late teens and early 20s, with 33-50% having no symptoms by adulthood.

 

tics1Test

 

Sometimes tics may be disruptive, irritating or hard to tolerate. If tics are misunderstood, likely the child will be asked to “stop it” and when this will not be possible may be punished or scolded. The resulting stress tends to worsen the tics and the adults may increase the punishing strategies. Over time this leads to poor communication, higher rates of depression, disruptive behaviors and developing maladaptive personality traits.

 

 

Coexisting Conditions

 

Children and adolescents with tics are likely to be diagnosed with other conditions as well like Attention Deficit Hyperactivity Disorder, Obsessive Compulsive Disorder or Learning Disorders. Many of them, in late adolescents will feel that the “other” problems (ADHD , OCD, LD) had an equal or greater impact on their life function than did the tics themselves.

 

 

Attention Deficit Hyperactivity Disorder

  • Up to 50% or more of the children with Tourette’s also have ADHD.
  • Typically ADHD precede the onset of tics.
  • Children with both Tourette’s and ADHD have a greater risk for social rejection, have more disruptive behaviors, more anxiety and mood disorders

Obsessive-Compulsive Symptoms

  • More than 40% of TS have persistent Obsessive Compulsive symptoms, some tic-related some not.
  • For example perfectionism with needs of symmetry and exactness, hoarding and counting rituals and touching and tapping compulsions.
  • Tics + OCD tends to be more difficult to treat than tics or OCD alone

 

 

Treatment – General interventions

 

  • Adults need to respond to outbursts of tics with grace and understanding.

 

  • A positive and supportive environment at home and in the classroom is critical.

 

  • The focus needs to shift from “need to stop” and blame to problem solving.

 

  • Educating peers and classmates is important. Peers need to know what the problem is and learn to disregard it. This education needs to be tactful and strategic if it is to reach to goal of increasing group support rather than rejection.

 

  • Scolding a child for his tics is counterproductive, leads to a negative attitude toward authority figures, increase teasing by classmates and tends to foster school avoidance.

 

  • If tics interfere with a student’s ability to receive information then alternative ways to present the material need to be considered.

 

  • Provide short breaks out of the classroom to let the tics out in private.

 

  • Allow students with severe tics to take tests in private so that a child does not have the pressure to suppress tics during the test period.

 

  • Skip oral presentations as they may be very difficult.

 

  • If there is teasing or bullying during unstructured settings one may consider an 1:1 aide.

 

Treatment – Psychological Interventions

The therapeutic interventions with highest rate of tic improvement are behavioral treatments like the Habit Reversal Training (HRT). The treatment has two main focuses:

Awareness Training

Designed to increase an individual’s awareness of his own tics.

Competing Response Practice

Teaching individuals to produce an incompatible physical response (for example contracting of tic-opposing muscles) after becoming aware of the urge to perform a tic.

 

Treatment – Pharmacology

Medical management of tics should be reserved only when tics are a significant source of impairment.

Generally, the coexistent conditions (ADHD, OCD) should be addressed first.

Generally, the treatment needs to be conservative, “start low and go slow”. The goal should be to use as little of these medications as possible to make the tics “tolerable.” Efforts to stop the tics completely often risk overmedication.

Clinical trials indicate that subjects can expect on average a 25 to 35% reduction in their symptoms over an 8 to 12 week period.

Most predictably effective treatment is the one with dopamine receptor antagonists (antipsychotics or neuroleptics). Examples include: haloperidol, risperidone, olanzapine and ziprasidone.

Fairly good results but overall better tolerability have been associated with the use of α2-receptor agonists . Example include: guanfacine and clonidine.

In cases with multiple coexisting conditions the decision making process is complex. Talk with your physician about options.

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