GV Basavaraja

National President 2024

An Algorithm
Yogesh Parikh
Secretary 2024–25 Approach
to Pediatric
Atanu Bhadra
Treasurer 2024–25

Advisor
Gnanamurthy Narasimha
National Scientific Convenor
Diagnosis
Sumitha Nayak

Core Team Members

B Rajsekhar
Janani Shankar
Kripasindhu Chatterjee
Nehal Patel
Rupesh Masand

Section Editor
Sumitha Nayak
Section Co-Editor
Priya Shivalli
 Tics in Children 25
Mrutunjay Dash

Definition

 Tics are brief and sudden movements or sounds that may be indistinguishable from physiological actions
but appear repetitive, often disruptive, and are not embedded in a certain context but can be inhibited
on demand.
 Tics are classified as a hyperkinetic movement disorder; however, different from other hyperkinesias,
they are typically preceded by a premonitory sensation known as the “premonitory urge”.

Classification

Classification of tics disease is illustrated in Table 1

Table 1: Classification of tics in children.
MOTOR TICS VOCAL TICS
Simple • Eye blinking • Whistling
• Eye rolling • Throat clearing
• Grimacing (pulling faces) • Sniffing
• Shoulder shrugging • Coughing
• Limb and head jerking/head nodding • Tongue clicking
• Abdominal tensing • Grunting
• Animal sounds
Complex • Jumping • Nonobscene socially inappropriate (NOSI)
• Twirling behavior (e.g., remarking about a person’s
• Touching objects and other people weight or inappropriately touching someone)
• Obscene movements or gestures (copropraxia) • Involuntary swearing (coprolalia)
• Repeating other people’s gestures (echopraxia) • Repeating a sound, word, or phrase (echolalia)
 Tics in Children

Red Flags

 Severe tics during early childhood

 Point to: Presence of common neuropsychiatric comorbidities, attention-deficit hyperactivity disorder
(ADHD) (50–80%), obsessive-compulsive disorder (OCD) (22–44%), learning difficulties (20–30%),
anxiety (20%), and sleep problems (64%).
 ADHD precedes the tic disorders and OCD usually follows tics.

Approach

 Detailed history, including age of onset, duration of tics, pattern, rhythm, family history, premonitory
urge, associated comorbid conditions, absence of any significant cause, absence of movement disorders
(athetosis, chorea, ballismus, myoclonus, etc.)
 Postviral encephalitis
 History of ingestion of any stimulant medications, Presence of pathological Huntington’s chorea to be
ruled out

(ADHD: attention-deficit/hyperactivity disorder; MOVES: motor tic, obsessions, and compulsions, vocal tic
evaluation survey; OCD: obsessive-compulsive disorder; YGTSS: Yale Global Tic Severity Scale) 3
 Tics in Children

Scales to Grade

Yale Global Tic Severity Scale (YGTSS) (Table 2)

Table 2: Yale Global Tick Severity Scale.

NUMBER FREQUENCY INTENSITY COMPLEXITY INTERFERENCE

TOTAL
0–5 0–5 0–5 0–5 0–5

Motor tics

Vocal tics

Note: Scoring:
1 = None, 10 = minimal, 20 = mild, 30 = moderate, 40 = marked, 50 = severe
Another scoring used is:
Motor tic, obsessions and compulsions, vocal tic evaluation survey (MOVES): This is a self-report scale for the
symptoms in five subscales: Motor tics, vocal tics, obsessions, compulsions, and associated symptoms
(echolalia, echopraxia, coprolalia, and copropraxia).

Management

 No specific laboratory tests

 If risk factors like dysmorphic facies, febrile seizure, unusual deterioration, and suspected chromosomal
anomalies occur, do neuroimaging, electroencephalogram (EEG), and exome sequencing.
 Group A streptococcal infection to be ruled out if suspected pediatric autoimmune neuropsychiatric
disorders associated with Streptococcus (PANDAS)
 Medication is the cornerstone along with behavioral therapy for severe tics.
 Motor tics respond better to medication than vocal tics.

4
 Tics in Children

Suggested Reading

 Ganos C, Martino D, Pringsheim T. Tics in the pediatric population: Pragmatic management. Mov Disord Clin Pract.
2017:4(2):160-72.
 Jain R, Pandey S, Raghav S. Movement disorders in children. Indian Pediatr. 2021;58(9):861-70.
 Rossi PJ, Opri E, Shute JB, Molina R, Bowers D, Ward H, et al. Scheduled, intermittent stimulation of the thalamus
reduces tics in Tourette syndrome. Parkinsonism Relat Disord. 2016:29:35-41.
 Ueda K, Black KJ. A comprehensive review of tic disorders in children. J Clin Med. 2021;10(11):2479.
 Weisman H, Qureshi IA, Leckman JF, Scahill L, Bloch MH. Systematic review: Pharmacological treatment of tic
disorders: efficacy of antipsychotic and alpha-2 adrenergic agonist agents. Neurosci Biobehav Rev. 2013:37(6):
1162-71.
 Yadegar M, Guo S, Ricketts EJ, Zinner SH. Assessment and management of tic disorders in pediatric primary care
settings. Curr Dev Disord Rep. 2019;6(3):159-72.