Tics In Childhood: Characteristics And Treatment

Tics are involuntary, recurrent, unpredictable, non-rhythmic muscle movements that can be temporarily controlled using willpower. Tics in childhood tend to get worse due to stress or anger, but can be reduced by distraction or concentration.

In fact, tics are one of the most common motor disorders in children. The involuntary part of the tics appears to be the first impulse, and the movement is often performed to relieve this impulse. However, younger children with rapid, repetitive tics describe them as something that suddenly appears, which they cannot control.

This is how they develop

Tics usually begin when the child is between four and seven years old. For most children, their first tics will cause repeated blinking, sniffing, whining or coughing. They are more common in men than women, with a ratio of 3 to 1.

The severity and frequency of tics vary considerably. However, many children between the ages of 4 and 6 with minor and transient tics are not taken to the doctor. In about 55% to 60% of young people, their tics will hardly be noticed at the end of adolescence or early adulthood.

In 20% to 25% of the others, tics become less frequent, and eventually, in the remaining 20%, tics continue into adulthood. Some of these adults will even notice that their tics get worse.

Clinical features of childhood tics

Some characteristics define these motor movements:

• Tics get worse with anxiety, fatigue, illness, excess emotions and excessive screen time.
• Tics tend to decrease when a child engages in a cognitively demanding and interesting task.
• Exercise will reduce tics, especially while actually engaging in physical activity.
• Tics will not interfere with important actions or activities, nor will they cause falls or injuries.

• However, there are tics that can be blocking and that can lead to these things, and in this case you should talk to a doctor who can diagnose the child and find out why they occur.
• You may notice a significant difference in tics when someone films the sufferer.
• They usually appear in people with personality disorders, as well as in dysfunctional families.
• Children can experience a feeling of joy that they express in the face.
• Those who suffer feel that they cannot suppress tics.
• They have no sense of when the movements will take place.

Classification of tics

Tics are classified as motor or vocal, and simple or complex. Simple tics are manifested by sudden movements or short, repetitive sounds. Complex motor tics are coordinated, inappropriate and sequential movements. Some examples of this are repeated shaking of the head, repeating what the other is doing (echopraxia), or making obscene movements (copropraxia).

Complex vocal tics are usually performed in inappropriate settings. An example of this is repeating syllables, blocking people’s words, repeating their words (palilali), repeating words one hears (echolali), or using obscene words (coprolalia).

How to classify tics in DSM-5

• Temporary tics disorder (transient). Motor or vocal tics (or both) that have lasted for less than a year.
• Chronic tics disorder. Some or more motor or vocal tics appear for more than one year.
• Tourette’s syndrome (TS). Several motor tics along with vocal tics that have lasted for more than a year. They do not necessarily have to be present at the same time, nor to follow a growing pattern.

Simultaneity in tics in childhood

Children with tics are usually unable to control their impulses. There are subtle differences in neuropsychological and motor function, as well as in a high rate of psychiatric or developmental comorbidities (where one or more conditions or symptoms are present). These include the following:

• ADHD (30% to 60%)
• Coercive actions (30% to 40%)
• Anxiety (25%)
• Disruptive behavior (10% to 30%)
• Mood Disorders (10%)
• Obsessive-compulsive disorder (5% to 8%)
• Autism Spectrum Disorder (5%)
• Motor coordination difficulties
• Fury

Etiology

Tics have a complex multi-genetic etiology and are highly inherited. The concordance between monozygotic twins is 87%.

In the past, tics were considered to be related to behavior or stress, and they were often called “nervous habits” or “contractions”. Experts now know that tics are neurological movements that can be aggravated by anxiety, but they are not caused by it.

The underlying mechanisms involve several neural networks in the brain, between the cortex and the basal ganglia (fronto-striatum-thalamus circuits). However, they also involve other areas of the brain such as the limbic system, the midbrain and the cerebellum. Abnormalities in interoseptic consciousness and central sensorimotor processing are also described.

Treatment of tics in childhood: Behavioral interventions

Behavioral interventions include several techniques. However, the specific treatment that each child needs will depend on the initial evaluation and response to the treatment, as well as the events that occur during it (Bados, 2002).

Both what is called habit reversal therapy (HRT) and main exposure and response prevention ( exposure and response prevention , ERP) are interventions tics based on evidence. HRT and ERP will reduce the overall severity and frequency rate ( Yale Global Tic severity score ) by between 40% and 50%.

Habit inversion treatment

Habit inversion therapy, proposed by Azrin (Azrin and Peterson, 1988), involves teaching the patient to recognize the impulse before tics appear. They then teach them to perform an action called competitive response , which reduces the chances of tics occurring.

This includes 11 main techniques that are organized into five phases:

• Awareness. This includes being aware of stimuli and situations that one experiences before tics appear.
  • Describe your tics in detail and then train yourself to do this on a regular basis.
  • Learn self-observation training to detect tics when they occur.
  • Early detection – training in how to detect sensations that you experience before tics.
  • Recognize dangerous situations where tics are more likely to occur.
• Relaxation training.
• Train yourself to react in a way that prevents tics from manifesting. The goal of this treatment is the following:
  • To prevent tics from appearing.
  • Keeping them away for several minutes.
  • To make the person increasingly aware of the situations in which tics appear, as well as the characteristics of them.
  • The methods should be socially acceptable.
  • They should also be compatible with the person’s regular daily activities.
  • It should strengthen these “enemy muscles” that are involved in causing tics, so that they are strong enough to avoid making these involuntary movements.
  • The training will usually consist of isometric tension of the muscles that are opposite to the tics movements.

Motivation

• Motivation. This phase is for both the patient and the family. It includes three standard motivational techniques:
  • To go over the negative effects of tics.
  • Social support. This includes getting someone close to you involved and helping you perform the procedure.
  • That you carry out these training methods in public.
• General training. This includes that the patient must imagine that they are performing the exercises in different dangerous situations identified in phase 1.

Exposure therapy with response prevention

The practice of being able to prevent exposure to and response to tics leads to a need for conditioning. This therapy therefore encourages the patient to feel and endure the need for tics (exposure) without letting them happen (response prevention). In a session of a certain duration, the therapist asks the patient to try to hold back and prevent tics. Then they record how long they are able to do just that.

This is not about achieving a specific time. Patients receive a lot of help in each session, and how long they can control their tics will increase over time.

Using exposure therapy with response prevention on a regular and systematic basis allows the patient to practice holding back the impulses to the tics. Over time, the patient’s ability to control them improves. During the session, the therapist asks the patient how strong the impulses are. This exposes them to the anxiety of having tics, despite the fact that they are just talking about it.

Pharmacological treatment of tics in childhood

The decision to use medication depends on the type of tics, and doctors usually use them only for severe and irritating tics that cause pain or injury. Current evidence shows that clonidine (a presynaptic alpha-2 agonist) is the first choice for medicines.

In contrast, antipsychotics or dopamine antagonists appear to be more effective in adults. Clinical practice supports good results with Aripiprazole in children.

Although doctors do not usually resort to benzodiazepines to treat tics, they sometimes use them in acute and severe cases. They can use them as a way to reduce anxiety when tics appear, but it is preferable not to use them, as they can have ripple effects that can cause other problems.