Tics (Pediatric) Overview

Note: In this section, several complex motor phenomena are defined, including tics, compulsions, stereotypies, mannerisms, and habits. Syndromes that have a sense of motor restlessness, including akathisia and restless legs syndrome, are also defined.

Tics are intermittent, repeated, stereotyped movements or sounds that may occur in an infrequent or almost continuous manner. Tics may be "simple," such as a cough, grunt, facial twitch, or shoulder shrug, or "complex," such as a word, phrase, or a stereotyped sequence of movements. Although tics appear similar to normal movement, they are not voluntary. There is often a sense of a build-up of the need to tic; this need increases if the child attempts to prevent the movement. Once the movement is made, there is a sense of temporary relief until the sense of the need for the movement begins again. The child may incorporate the tic movement into an apparently voluntary gesture; this is done in an attempt to avoid embarrassment.

A child may fulfill the criteria for Tourette's syndrome if...

• They have multiple motor tics (e.g., any kind of movement of the limbs, trunk, or face)
• They have at least one vocal tic, involving any sound (except coughing or sniffing)
• Symptoms begin before the age of 21 years
• Symptoms wax and wane over a period of more than one year

If only motor tics are present, the disorder is referred to as "chronic motor tic disorder." Tics often become worse when the child is nervous, stressed, upset, or concentrating.

Tics are very common. By some estimates, up to 10% of boys experience tics at some time during childhood. Tics are slightly less common in girls. Most tics resolve spontaneously and do not require treatment, unless the symptoms interfere with school or social interactions. Tic disorders frequently occur in association with compulsions and attention-deficit disorder (ADD). The cause of tics is unknown; however, several family members may be affected, suggesting a genetic component. The severity and nature of tics change throughout life. They may wax or wane over months or permanently disappear for years.

Compulsions are complex behaviors that respond to a psychological need. These behaviors are different from tics in that the movement may be repetitive and ritualistic. The detailed movements are often not stereotyped, and there is a distinct purpose to the movements. Frequently, the child has an almost superstitious concern over the consequences of not performing the compulsion. Examples include...

• Compulsive hand washing, due to a fear of germs
• Multiple unlocking and re-locking of a door, due to concern over possible intruders
• A need for symmetrical movements or placement of objects
• Counting behavior
• Fixed routines or patterns of behavior
• Obsessive thoughts

The actions "feel" voluntary, but the child may describe a sense of fear or impending doom if the action is not performed. Compulsions are frequently associated with obsessions, tics, or Tourette's syndrome.

Stereotypies are repetitive, stereotyped, purposeless movements that may be made by normal children when they are bored, excited, or engrossed in an activity. Stereotypies are often associated with attention deficit disorder (ADD), developmental delay, or autism. They may consist of hand flapping, clapping, slapping, fluttering, rocking, or facial movements. These children are not necessarily aware that they are making the movements. In some cases, these movements can be voluntarily suppressed.

Mannerisms are the particular embellishments that people develop while performing certain movements or gestures. These mannerisms are normal voluntary phenomena; however, in some cases, they may appear abnormal, particularly if the mannerism involves unusual or unnecessary postures. An example might be the extension of the little finger while holding a teacup. This mannerism was common during the 19th century. However, it is important to be sure that a mannerism does not represent a "covering-up" of a dystonia, tic, or other involuntary movement disorder.

Habits are more complex or purposeful movements. There is no sensation of a build-up of the need to move prior to performing a habit or mannerism. The child can modify the movement if necessary.

Akathisia describes a sense of restlessness leading to the child's need to move or walk. The feeling is very uncomfortable and the movements are voluntary, in response to a need to move. These symptoms appear similar to anxiety. The sensation may lead to pacing or to rubbing the legs, face, or scalp with the hands. The most common cause of akathisia in children is a reaction to neuroleptic medications such as haloperidol (Haldol®) or pimozide (Orap®).

Restless legs syndrome (RLS) involves unusual sensations (paresthesias/dysesthesias) under the skin. These sensations have been described as creepy-crawly, burning or prickly. Paresthesias are accompanied by an urgent need to move the affected body part. The sensations, which commonly occur in the legs, are temporarily relieved with voluntary movement. The feelings "build up" until the child moves, rubs the legs, or stands up. There is a subsequent sense of relief; however, the abnormal sensations return. The leg movements are under the child's control, but the child is unable to suppress these movements due to the discomfort that comes with sitting still. There seems to be a certain pattern (Circadian rhythm) to the symptoms (e.g., more noticeable at night, less pronounced during the day). In some cases, RLS is associated with periodic leg movements of sleep (PLMS). PLMS are repetitive, intermittent movements of one or both legs and feet; these movements occur during sleep.

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