Tics and Tourette Syndrome

All questions and answers are in this special guide for parents by Dr. Yoram Belzer, a pediatric specialist with the Clalit Group, and Dr. Moti Haimi, a specialist in pediatrics and hemato-oncology at the Children’s Health Center in Haifa, part of the Clalit Group.

Generally, tics are short, sudden, involuntary movements involving different muscle groups. These movements intermittently repeat and are purposeless. They are often recognizable, such as blinking, nose or mouth movements, or shoulder movements. Sometimes, there are combined movements affecting areas such as the face, shoulders, and arms simultaneously.

What are motor tics?

Tics are classified as motor tics when they involve only movement. These movements occur against the backdrop of normal motor activity.

Motor tics are chronic and may appear during childhood, continue into adolescence, and possibly beyond. These tics originate in the brain—our central nervous system. The issue arises from a disruption in the activity of dopamine receptors, which are hormones involved in nerve cell communication in the brain.

Simple motor tics involve a single muscle group. They appear and disappear intermittently and are likely to vanish within a few months to a year after initial onset.

Complex motor tics involve the activation of various muscle groups. The movement of the tic starts in one part of the body, such as the face, and moves to another area of the body, possibly accompanied by a variety of sounds.

Tics can change character over time. Initially, they may present as blinking for a few weeks and later turn into facial muscle distortion or nose movement. However, multiple types of tics can occur simultaneously.

What are vocal tics?

A vocal tic involves sound production using the vocal cords, manifesting as various sounds: throat clearing, persistent coughing, grunting, or other involuntary noises without purpose or reason. Vocal tics occur intermittently and are unpredictable and sudden. More complex tics may include repeated words or phrases.

The Discovery

Is this a common phenomenon? At what age do tics appear?

Tics appear between ages 5 and 10. Various surveys indicate that 10% to 15% of children will develop tics at some point during childhood, although for most, they will resolve on their own. Tics are more common in boys than in girls.

While tics are a neurological phenomenon, they can be influenced by emotional states: tics can worsen in times of stress and anxiety or during illness or extreme fatigue.

Are tics related to developmental issues?

Most children with tics have no intellectual or developmental issues. However, tics can occasionally appear alongside developmental disorders and other syndromes, such as attention deficit hyperactivity disorder (ADHD) and autism. Children with tics may also exhibit a higher incidence of emotional difficulties or obsessive thoughts.

The Treatment

How are tics treated?

In most cases, tics are a transient phenomenon that do not cause significant disruption to daily life and therefore do not require treatment.

In more severe cases where the tics are troublesome, interfere with daily functioning, or cause social issues, medication may be prescribed, often combined with behavioral therapy.

What is Tourette Syndrome?

Tourette Syndrome is a neuropsychiatric disorder first identified by French neurologist Georges Gilles de la Tourette in 1895. It is characterized by repetitive involuntary movements and vocalizations, as described above. These movements are called "tics."

Do tics always indicate Tourette Syndrome?

No. Tics can be divided into different types, and only one type, which is less common, indicates Tourette Syndrome. Most cases involve transient tics as part of a transient tic disorder, the most common movement disorder in children. It is more frequent in boys than girls and is often prevalent within families.

As mentioned, a tic can manifest in various movements: eye blinking, brief facial contortions, lip twitching, nose pulling, peculiar head movements, or short, purposeless limb movements.

This disorder is not Tourette Syndrome and occurs in about 10% of school-age children, typically lasting only a few months (up to 4 months).

Tourette Syndrome, however, persists throughout life, with a prevalence of 0.05% (1 in 2,000). Symptoms first appear between ages 5 and 10, but can also first occur in the early 20s. Tics associated with Tourette Syndrome last more than a year.

In Tourette Syndrome, various types of tics—some simple and some more complex—usually occur, along with a variety of sounds. The initial presentation usually involves motor tics in areas like the face, neck, or arms.

Motor tics typically accompany at least one vocal tic. The variety of motor tics is extensive. These may present as eyelid blinking, eye gaze shifts, lip contortions, shoulder movements (such as shrugging), feet stamping, or touching objects or body parts.

Vocal tics can manifest in various forms: throat clearing, barking coughs, groans or sighs, coprolalia (involuntary use of offensive language), and automatic repetition of heard words and sounds. Another common feature is compulsive (obsessive) behavior and sometimes ADHD.

Uncontrollable vocal tics threaten the child's social interactions with peers.

The Diagnosis

How is Tourette Syndrome diagnosed?

It appears that this disorder has a genetic basis: there is an increased prevalence of the syndrome in certain families. However, in some cases, the issue arises from non-genetic sources, as a side effect of another problem (such as a brain injury).

Regarding diagnosis, some of the phenomena described earlier can also appear in other diseases, so it is important to seek medical advice to determine that it is indeed Tourette Syndrome. Unfortunately, there are no lab or imaging tests to diagnose Tourette, so diagnosis is solely clinical, including a full medical consultation (family history included), physical examination, and child behavior assessment. Sometimes tests like EEG or brain imaging are conducted to rule out other diseases.

As noted, several other disorders may be associated with Tourette Syndrome. These often involve obsessive-compulsive behavior, but ADHD can also accompany Tourette Syndrome.

Is there a treatment for Tourette Syndrome?

It is important to emphasize that most children with Tourette Syndrome function well both at home and school. Therefore, the decision to treat depends on the clinical severity of the syndrome, the extent of its interference in daily life, and any neurological symptoms associated with the syndrome—if such symptoms exist.

If the severity of the tics is not high and they are not disruptive in daily life, medication is usually unnecessary. If Tourette Syndrome is accompanied by ADHD and hyperactivity, the treatment focuses on the accompanying issues, not the syndrome itself. When obsessive and ritualistic thoughts are the problem, medication aims to address these issues, which can also reduce tic frequency. Emotional difficulties can be treated using psychotherapy.