A previously healthy 10-year-old female came to clinic with new onset of eye blinking that the mother had noticed for 2 weeks. The patient initially didn’t notice it, but was becoming more aware and said that she noticed it occurred more when she was upset or excited. Her friends had not noticed it. The eye blinking didn’t seem to bother her in general and the mother said that she saw only increased eye blinking in the evenings particularly when she was tired. They both agreed that she was only having eye blinking and denied any abnormal motor or vocal movements despite extensive examples. The patient denied any visual changes, photophobia, changes in tearing, or erythema of the eye structures. The past medical history was positive for seasonal allergic rhinitis, but the patient was not having any other allergic symptoms. The family history was positive for eye blinking and cheek puffing tics in her mother as a child that resolved before middle school. There was no neurological, psychiatric or school problems in the family. The review of systems was negative.
The pertinent physical exam showed a cooperative female with increased eye blinking throughout the examination. Her growth parameters were at the 90%. Her vital signs were normal. Visual acuity was 20/25 in the left eye and 20/20 in the right. Eye examination was normal as was the rest of her examination. The diagnosis of a simple or provisional motor tic was made. The family was counseled that most of these resolve within a few weeks to months, but it could be persistent. It could also herald the beginning of other tics. As the current tic was not bothering her, the family was told to continue to monitor it and if it became more of a problem or if more complex motor or vocal movements began, to contact the office. The patient’s clinical course showed an increase in the eye blinking for about 2 months, then it resolved. At two years later she had no other tics.
Tics are usually single repetitive, non-rhythmic, non-purposeful movements or utterances. Tics can be multiple and complex however. Tics may be preceeded by a premonitory urge where the person has a feeling that a certain type of tic is going to occur and then this feeling goes away after the tic is produced.
Tics, especially simple motor tics, are very common with ~10-15% of elementary age children having a tic at some time. In one community-based study, the overall prevalence was 3-9% with an overall frequency of 24% of elementary school children during one school year. Tics are more common in boys and present around age 6-12 years, but may be not recognized until as late as 21 years. They are usually most severe around 10-12 years of age. Motor tics usually appear 2-3 years before vocal tics but vary with the individual. Tics can last for a few weeks, months or be chronic (> 1 year of symptoms). Simple tic or provisional tics last less than 1 year. Chronic or persistent tics last more than 1 year. Note that the definitions are based on timing of symptoms not the severity or the complexity of the tics themselves.
Tourette syndrome (TS) is a particular type of tic but for the lay public may be the most well known. It is a chronic tic disorder where patients have both motor and vocal tics, although these may occur at different times. Patients with TS also have psychiatric symptoms such as obsessive-compulsive disorder, attention deficit disorder, depression, anxiety and others. Patients often have complex tics. The tics must have started before age 18 and they cannot be due to medications or other medical conditions to be diagnosed with TS.
Treatment is education and watchful waiting mainly with patients with complex, chronic or tics that are disturbing using a variety of alpha-2 agonists, anti-psychotics and botulinum toxin. Habit reversal training or different types of electrical brain stimulation have also been used.
The prognosis in most children is generally good with resolution for many patients. Unfortunately, despite research at this time, there are no specific predictive signs, symptoms or tests which can determine the prognosis for an individual.
The differential diagnosis of other involuntary movement disorders includes:
- Chorea and choreoathetosis
- Reflexes – Moro, startle
- Spasmus nutans
- Torticolis, spasmodic
- Torsion spasms
- Rett syndrome
- Stereotypical movements with autism
The most common motor tics involve the face and head with ocular tics being particularly common. The most common vocal tics are throat clearing and sniffling which can be misdiagnosed as allergic symptoms or asthma. Patients with Tourette Syndrome (TS, discussed above) and those with other types of tics have other unusual behaviors such as echolalia (repeating someone else’s words), pallilalia (repeating one’s own words), coprolalia (obscene speech), echopraxis (repetitive gestures), copropraxis (obscene gestures), and coprographia (obscene writing). These behaviors are considered complex tics.
Questions for Further Discussion
1. What is PANDAS and how is it related to tics?
2. What is the Yale Global Tic Severity Scale?
- Symptom/Presentation: Behavior Problems
- Age: School Ager
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Illingworth RS, Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:227-234.
Snider LA, Seligman LD, Ketchen BR, et. al. Tics and Problem Behaviors in Schoolchildren: Prevalence, Characterization, and Association. Pediatrics. 2002;110;331-336.
Shprecher D, Kurlan R. The management of tics. Mov Disord. 2009 Jan 15;24(1):15-24.
Siniatchkin M, Kuppe A. Neurophysiological determinants of tic severity in children with chronic motor tic disorder. Appl Psychophysiol Biofeedback. 2011 Jun;36(2):121-7.
Ludolph AG, Roessner V, Munchau A, Muller-Vahl K. Tourette syndrome and other tic disorders in childhood, adolescence and adulthood. Dtsch Arztebl Int. 2012 Nov;109(48):821-288.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital