Tics – when it’s time for intervention

Abstract

Tics are sudden, repetitive, and arhythmic motor movements or vocalizations that most often occur in childhood. They are a common reason for referral to a pediatrician or child neurologist, and they encompass a spectrum of disorders – from transient and mild symptoms to chronic and functionally disabling neurodevelopmental conditions.

They most often appear between the ages of 4 and 8, while the peak severity of symptoms is around 10 and 12 years of age. Boys are affected more often than girls. The course of tic disorders is typically waxing and waning, with symptoms fluctuating in type, frequency, and severity over time. Stress, fatigue, excitement, and emotional tension can worsen symptoms.

The classification of tics is based on the clinical picture, duration of symptoms, and etiology.

According to the clinical picture, tics are divided into motor and vocal. Motor tics can be simple (e.g., blinking, grimacing, head jerking, shoulder shrugging) or complex (e.g., coordinated movement patterns, touching objects, echopraxia). Vocal tics are also divided into simple (throat clearing, sniffing, coughing, grunting) and complex (uttering words or phrases, echolalia, palilalia, coprolalia).

According to the duration, there are transient tics that last less than a year and persistent (chronic) tics that last more than a year.

Etiologically, tics can be primary (idiopathic) or secondary.

The pathophysiology of primary tics is complex and involves the interaction of genetic, neurobiological, and environmental factors. Tics are considered a disorder of motor inhibition regulation within the cortico-striato-thalamo-cortical circuits, which are crucial for the control of voluntary movements and the suppression of undesirable motor patterns, with a strong influence of the dopaminergic system and developmental factors.

Secondary tics occur as a consequence of other conditions, including drug side effects, brain injury, infections, or autoimmune processes. One of the proposed immune-mediated entities is PANS, characterized by the sudden onset of tics and/or obsessive-compulsive symptoms related to infection, and in this group, PANDAS stands out, which is closely associated with streptococcal infection.

Accurate classification of tics is crucial for proper diagnosis, prognosis assessment, and therapeutic planning.

Neuroradiological and laboratory examinations are usually not necessary except in severe clinical cases and suspicion of secondary tics. Treatment depends on the severity of symptoms and functional impairment. For mild tics, education and monitoring are often sufficient. The first line of therapy for more severe symptoms is behavioral therapy, while pharmacological treatment is applied according to individual assessment and most often for secondary tics.