I see that Jonathan's name is on the schedule for today. He is coming in for his 18 month visit. The chart indicates that he hasn't been in the office since his one year visit, so I assume that all has been going well for him. When I enter the room, I see that his mom is very anxious. Within minutes of the visit, she tells me that for the past two months, Jonathan has been blinking his eyes for no apparent reason at all. His vision appears to be keen, it seems to be an involuntary movement. She has been told by friends that it is just a "tic"...not to worry about it. Needless to say, she is extremely worried.
Kevin is a ten year old that I have cared for since he was born. He too, has a tic disorder--one that we have been dealing with for the past three and a half years. He is in today because of a sore throat and a fever. As I ask him about his sore throat, he clears his throat and blinks his eyes. His face grimaces as he repeats the word throat, about five times. Kevin has a more complex type of tic disorder. He has Tourette Syndrome.
Tic disorders represent a continuum, or a broad spectrum of behaviors that range from a mild, transient condition--to a more severe, persistent and often debilitating disorder that can wreck havoc on a child's life. A tic is an abrupt, brief involuntary movement that is repetitive and serves no useful purpose. It can be a coordinated movement (motor), or a form of phonation (vocal).
One major classification of tic disorders is dependent upon how long they last. If a tic is present for less than a year, it is considered to be a transient tic. If it occurs for longer than a year, then it is a chronic tic. Transient tics occur in about 10-24% of all school-aged children at some time during their childhood. Most of these are mild, and do not interfere with the child's life or self-esteem. Because they are "transient," they usually resolve within twelve months.
Tics can be further classified into simple, or complex tics. Simple motor tics involve an individual muscle group and produce a brief and instantaneous movement such as an eye blink or wink, raising the eyebrows, wiggling the nose, head jerking or shrugging the shoulders. Simple vocal tics can manifest as grunting, snorting, sniffing, throat clearing or coughing.
Complex motor tics involve a grouping or clustering of simple motor tics, or a coordinated pattern of movements such as facial grimacing, touching oneself, hitting, skipping, jumping, twiddling one's hair or smelling one's hands or objects. A small percentage of patients with complex motor tics may exhibit copropraxia which is using obscene gestures. Complex vocal tics include uttering syllables, words or phrases, or repeating their own words or words of others. In some instances, they may utter obscenities (coprolalia).
There are some important facts to be aware of regarding tics in general. First of all, they are involuntary. The child has NO control over them and they are NOT done on purpose, or out of defiance. Tics will wax and wane over time, but they are predictably more prominent during times of emotional stress, excitement or anger. The inadvertent "nagging" of a well-intentioned family member or teacher will only serve to make the tics worse. It is, therefore, counterproductive to scold or reprimand a child for their tics. Just as tics are more pronounced during times of stress, they are less frequent during enjoyable and absorbing activities such as playing video games or watching a movie.
Once a child develops tics, there is no predicting which will be transient or which will become chronic. There are no tests available to diagnose a tic disorder. These children have normal neurological exams, normal EEG's (brainwave tests), and normal CT scans and MRI scans of the brain.
Tourette Syndrome (TS) represents the more complex form of tic disorder...the opposite end of the spectrum. TS is defined as the presence of chronic motor tics accompanied by one or more vocal tics that has a waxing and waning course. Over time, the motor tics may change, or be replaced with new ones.
TS is four times more common in males than females, has a mean age of onset around 6-7 years, occurs in all races with a predominance in Caucasians, must have it's onset before the age of 21 years, has an incidence of around 5 per 1000 people, and is felt to be genetically transmitted. At one time thought to be a lifelong disorder, current research indicates that as many as 25% of all cases of TS will resolve completely by the time the child reaches late adolescence.
Patients with TS can also have other associated disorders such as Obsessive-Compulsive Disorder (OCD), Attention Deficit Disorder (ADD) or Learning Disabilities,. Quite often these can be far more disruptive to the child's life that the TS itself.
The treatment of tic disorders is extremely varied and must be tailor made to meet the needs of the individual child. Most simple transient tics do not require any specific treatment. Reassuring the parents and teachers that the tics are not voluntary or done purposefully is important, as is trying to minimize the stressors for the child. The parents must realize that a child with tics must follow limits, rules and boundaries just as any other child or sibling. No exceptions must be made. If it gets to the point whereby a child with tics is being ridiculed or teased, and is becoming self-conscious about it, then treatment with a medication to control the tics may be warranted.
In most cases of TS, the tics are usually severe enough to cause a significant impact on the child's life, thus requiring treatment. Since most of the drugs used in the treatment of TS are not without their individual side-effects, the choice of treatment must be made on an individual basis by the doctor. In evaluating a child with TS, it is critical to be on the look-out for associated problems such as OCD, ADD and Learning Disorders. These can be subtle and are often over-shadowed by the overt nature of the TS. When these disorders do occur concomitantly with TS, the treatment is more complex and often requires the assistance of a specialist.
In Jonathan's case, his mother was comfortable with his "tics" knowing that it wasn't anything serious or dangerous. It was hard for her to "back off" at first and not constantly remind him each time he blinked his eyes. Things did improve after a few months. In fact, when he came in for his two year visit, I had to remind her of the tics. She had almost forgotten about them since he had not had a tic for over two months.
Kevin's case was not so simple. Kevin is a bright 5th grader who has had a difficult time with his TS. In 2nd grade he was diagnosed as having ADD. At that time, he was already having a some motor tics, but it was in no way a problem for him. The ADD was diagnosed because of school under-achievement...he was bright and gifted, yet, school was a struggle for him. After a thorough work-up was completed, the ADD was diagnosed and he was started on Ritalin. It was a tremendous success. His school performance improved overnight---but the tics worsened. It was obvious that he, in fact, had TS, and he developed all of the classic signs. The tics were not only interfering with his school work, things at home were out of control. His inter-personal and peer relationships were becoming a disaster. It is well-documented that the use of stimulant medications for the treatment of ADD (Ritalin and Dexedrine) can exacerbate or worsen the tics in people that are predisposed. With this turn of events, Kevin was referred to a specialist who kept him on the Ritalin, but added another medication, Clonidine, to control the TS. Kevin is now an honor student, is thriving socially in school, has plenty of friends, and is an outstanding baseball player.
Tic disorders and Tourette Syndrome represent a fascinating and interesting spectrum of behavioral disorders. It is a complex topic and one that is poorly understood by the general public. There is a fair amount of mis-information out in the community about tics and TS. For more information about TS, a good source of information is the Tourette Syndrome Association which can be reached at this toll-free number 1-800 237-0717.