Tics in children

What are tics?

Tics are rapid, involuntary movements that repetitive but have no specific pattern or rhythm. The tics can manifest in either a simple movement or a complex one, with or without vocalizations, and tend to have repetitive characteristics.

What different types of tics exist?

Tics can be divided into two types – motor tics, which are tics that manifest as repetitive movements and vocal tics, which are tics that manifest in vocalizations or words.
These two different types of tics can be divided according to their degree of severity to either simple or complex tics. Here are some explanations and examples:

Motor tics such as eye tics, facial tics, bodily tics, neck tics and head tics

Simple motor tics – rapid and quick movements that involve either one muscle or a group of muscles. For example, twitching of the eyes (find out more about eye twitching in children here), rapid movements of the head, movements in the neck region, opening of the mouth with or without taking in a deep breath, etc.
Complex motor tics – a series of simple tics or more complex movements that require a certain degree of coordination. For example: jumping, skipping or repetitive touching of a specific area.

Vocal tics

Simple vocal tic – making simple sounds and noises that are insignificant such as clearing of the throat, cough (sometimes referred to as a habitual cough, see this link), a bark, sniffing tics, etc.
Complex vocal tic – repetition of words or parts of words, phrases, sentences, repeating a sentence someone else said and rarely repeating a curse.

What are the unique characteristics of tics?

It is important to keep in mind that there is a differential diagnosis to repetitive movements in children as they are are not always a manifestation of tics. So, other than the different types and definitions mentioned above, tics have their own specific characteristics when compared to other repetitive movements:
1. Tics come and go. Sometimes they intensify in frequency and other times they occur less frequently.
2. Most of the time there is a combination of new and old tics, old tics are renewed by new ones and sometimes old tics that had previously resolved reappear.
3. Most of the time there is a worsening of the tics as a result of stress, anxiety, excitement, etc.
4. The tics resolve when the child is distracted by something that interests them, is practicing physical exercise and during sleep.
5. About half of the children who experience tics (and 90% of adults, by the way) report that just before the onset of the tic they get a strong involuntary sensation/an unpleasant feeling that causes them to perform the tic and after they have done so they feel a relief.

How common are tics in children?

About 6-12% of children experience tics.
Most of the time it starts at around the age of 6. There is a tendency for it to get worse, and to intensify in severity and frequency at ages 8-12 years.

Are there any causes for the onset of tics?

The cause of tics is unknown. Nonetheless, we know that the condition has a strong genetic base because in monozygotic (identical) twins, when one twin experiences tics, there is about 80% chance that the other twin will experience tics as well. In dizygotic twins (non-identical), the chances are reduced to 20%.
However, usually genes are not the only factor involved, and similarly to other medical conditions, the effect of the environment can cause the genetic tendency to manifest.
There are, of-course, theories about neural brain changes that are associated with the onset of tics but that is beyond the scope of our chapter.

Are there additional factors that are associated with the onset of tics?

This is interesting, but yes, there are possibly additional factors associated with the onset of tics.
Tics following infections – this is a condition that is associated with the immune system’s reaction following an infectious disease (viral/bacterial), with or without direct involvement of the central nervous system. Here we should mention PANDAS (which stands for Pediatric Autoimmune Neuropsychiatric Disorder associated with group A Streptococci) which is a syndrome that occurs following a streptococcal infection and it manifests in symptoms similar to the ones seen in obsessive compulsive disorder (OCD) and sometimes, in tics. Please note that this is not a common syndrome (in fact, it is borderline rare) and therefore this diagnosis will be given to a child with great care, following meticulous history taking, taking into consideration the entirety of the clinical symptoms of the child’s disease.
Tics as a side effect of certain drugs, such as drugs that improve attention.
Tics following poisoning.
Tics following head trauma or other situations that can cause damage to brain tissue.
Tics that manifest as part of an underlying systemic medical disorder.
Practically speaking, 99% of tics are simple and resolve spontaneously, are not a manifestation of a disease or syndrome and are not supposed to affect the child’s quality of life or functioning.

Are there conditions/diseases in children where tics occur at a higher rate?

Yes. It is important to note that most of the time, the accompanying disorders are what affect the child’s quality of life, and not the actual tics.
Tics in children who have ADHD (Attention Deficit and Hyperactivity Disorder) – signs and symptoms of ADHD can manifest 2-3 years prior to the onset of tics (in about 50-80% of cases).
There can be additional disorders accompanying tics such as anxiety, that affects the child’s quality of life regardless of the presence of tics and therefore it is important to detect these disorders and to offer adequate treatment.

Are tics a chronic condition for life?

Fortunately, they are not.
Following a peak around ages 8-12 years, as mentioned above, there is usually a spontaneous improvement, and it follows the “one-third rule”.
In one third of the children the tics resolve.
In one third of the children the tics improve (their intensity and frequency is reduced).
In one third of the children, they continue into adulthood.
In this context, we can also mention a few additional definitions:
1. Transient tic disorder – one or several types of tics, motor, vocal or both, that occur for different periods of time, sometimes several times a day, but usually resolve within less than a year.
2. Chronic tic disorder – one or several types of different tics, either motor or vocal (but not at the same time, see Tourette syndrome below), that occur for a period that is longer than one year.
3. Tourette syndrome

What is Tourette?

Tourette syndrome is a neurological syndrome that was named after the French neurologist, Dr George Gilles de la Tourette, who discovered it.
The diagnosis of Tourette syndrome is based on a set of unique criteria. The main criterion is that children with Tourette have both motor tics and vocal tics – both have to be present, but they do not necessarily have to occur at the same time, and they last for longer than a year.
Tourette syndrome is more common in boys, it is seen in about 0.1-3% of the general population, it starts around the age of 5-7 years (must start prior to age 21 by definition) and resolves in about 30-50% of cases.

Do tics need treatment?

Tics are not a disease. Tics represent a certain tendency that uncovers because of what we call in medicine a “trigger”. Some sort of stimulus.
The approach to treatment of tics depends on the child and their family. It is important to try to understand, as best as possible, what the things that affect the child’s general well-being and functioning are, and to try to offer interventional treatment accordingly.
Interventional treatment does not necessarily mean a specific treatment and in most of the cases the right treatment simply entails reducing stress from the child, and teaching the family to take on the right approach towards these tics.

How are tics treated?

Just like any other medical condition, it is important to explain to the child and family what these tics are, what their significance is and what the future holds. Understanding that this is usually not an illness, and that there is a great chance that it will resolve / improve helps a lot with handling the difficulties.

There is no place for commenting and asking the child to “stop” the tics because they are not in his/her full control and therefore this does not contribute to improving the situation, but rather exacerbates it. There is no place for anger or punishments.

As mentioned above, the treatment for tics themselves is reserved for those children whose tics are very disturbing and affect their general well-being and functioning.
It is important to keep in mind that there isn’t a specific medical treatment that can be taken to “cure” tics. The treatment must be wholesome and must tend to all the different factors contributing to the child’s feelings and functioning. Treating the tics can be one of several elements and is not necessarily the most important one.

Firstly, it is important to treat accompanying conditions, should they be present (anxiety, OCD, ADHD), if these are affecting the child’s functioning. Therapies that can be offered to manage tics and accompanying disorders will then include two important aspects:
Different types of behavioural therapies that are based on being aware of the need to perform the tic and building ways to try and manage this need.
Different groups of pharmacological therapies can be offered in very severe and resistant cases.

In summary, this is a super common condition in children. See your pediatrician for an assessment. Try to contemplate whether there is a need for intervention, and if so, when, together with your pediatrician. Being angry and portraying stress towards the child are not helpful at all, because the child is not in control of these tics.
In exceptional and prolonged cases, see a pediatric neurologist that specializes in the field.