{"id":4469,"date":"2022-05-03T11:47:20","date_gmt":"2022-05-03T10:47:20","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/ticdisordersincludingtourettessyndrome\/"},"modified":"2023-09-14T15:36:53","modified_gmt":"2023-09-14T14:36:53","slug":"ticdisordersincludingtourettessyndrome","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/paediatricneurology\/ticdisordersincludingtourettessyndrome\/","title":{"rendered":"Tic Disorders (including Tourette&#8217;s Syndrome)"},"content":{"rendered":"\n<p><strong>Information<\/strong><\/p>\n\n\n\n<p><strong><em>Prevalence<\/em><\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><em>5% lifetime prevalence of provisional tic disorder<\/em><em><sup>2<\/sup><\/em><\/li>\n\n\n\n<li><em>0.77% overall prevalence of Gilles de la Tourette&#8217;s syndrome<\/em><em><sup>4<\/sup><\/em><\/li>\n\n\n\n<li><em>More common in children than adults, in boys than girls, and in special education populations<\/em><em><sup>4<\/sup><\/em><\/li>\n\n\n\n<li><em>More than half of children with Tourette&#8217;s syndrome may have Attention Deficit Hyperactivity Disorder (ADHD)<\/em><em><sup>3<\/sup><\/em><\/li>\n<\/ul>\n\n\n\n<p><strong><em>DSM-5 Definition and Diagnostic Criteria<\/em><\/strong><strong><em><sup>1<\/sup><\/em><\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><em>Tics: Sudden, rapid, recurrent, non-rhythmic motor movements or vocalisations<\/em><\/li>\n\n\n\n<li><em>Vocalisations can be simple sounds (e.g. sniffing, throat clearing or coughing), or complex vocalisations (e.g. coprolalia); also includes speech blocking or stuttering-like symptoms<\/em><\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-table is-style-regular\"><table><tbody><tr><td><strong><em>Provisional tic disorder<\/em><\/strong><\/td><td><strong><em>Persistent (chronic) motor or vocal tic disorder<\/em><\/strong><\/td><td><strong><em>Tourette&#8217;s disorder<\/em><\/strong><\/td><\/tr><tr><td><em>\u22651 motor&nbsp;<\/em><em>or<\/em><em>&nbsp;vocal tics<\/em><\/td><td><em>\u22651 motor&nbsp;<\/em><em>or<\/em><em>&nbsp;vocal tics present during the illness, but not both<\/em><\/td><td><em>\u22652 motor&nbsp;<\/em><em>and<\/em><em>&nbsp;\u22651 vocal tics present at some time during the illness, although not necessarily concurrently<\/em><\/td><\/tr><tr><td><em>Tics present for &lt;1y since first tic onset<\/em><\/td><td><em>Tics persisted for &gt;1y since first tic onset (frequency may wax and wane)<\/em><\/td><td><em>Tics persisted for &gt;1y since first tic onset (frequency may wax and wane)<\/em><\/td><\/tr><tr><td><em>First tic onset &lt;18y<\/em><\/td><td>\u200b<\/td><td>\u200b<\/td><\/tr><tr><td><em>Not attributable to substance<\/em><em><sup>*<\/sup><\/em><em>&nbsp;or medical condition<\/em><em><sup>\u2020<\/sup><\/em><\/td><td>\u200b<\/td><td>\u200b<\/td><\/tr><tr><td><em>Criteria for Tourette&#8217;s disorder or persistent (chronic) motor or vocal tic disorder not met<\/em><\/td><td><em>Criteria for Tourette&#8217;s disorder not met<\/em><\/td><td><em>&nbsp;<\/em><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p><em><sup>*<\/sup><\/em><em>Medication, cocaine<\/em><em>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/em><em><sup>\u2020<\/sup><\/em><em>Huntington&#8217;s disease, post-viral encephalitis<\/em><\/p>\n\n\n\n<p><strong><em>Diagnosis<\/em><\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><em>Diagnosis is made clinically from history and examination<\/em><\/li>\n\n\n\n<li><em>No role for investigation if diagnosis is certain<\/em><\/li>\n<\/ul>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p>Referral Guidelines:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><em>No referral required if diagnosis of tic disorder certain<\/em><\/li>\n\n\n\n<li><em>Refer to General Paediatrics in the first instance if diagnosis uncertain<\/em><\/li>\n\n\n\n<li><em>If diagnosis still uncertain:<\/em>\n<ul class=\"wp-block-list\">\n<li><em>Discuss with Paediatric Neurology (for video review of movements) for a child with no neurodevelopmental co-morbidity<\/em><\/li>\n\n\n\n<li><em>Discuss with Community Paediatrics for a child already known to CCH with a neurodevelopmental disorder<\/em><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><em>Refer to Child and Adolescent Mental Health Service for management of:<\/em>\n<ul class=\"wp-block-list\">\n<li><em>neurodevelopmental\/psychological co-morbidities (e.g., depression, anxiety, ADHD, OCD)<\/em>\n<ul class=\"wp-block-list\">\n<li><em>treating these conditions may improve tics<\/em><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><em>severe tics impacting activities of daily living or mental health (consider quantifying with Yale Global Tic Severity Scale)<\/em>\n<ul class=\"wp-block-list\">\n<li><em>CBT has best evidence of efficacy; requires high degree of engagement so more suited for older children<\/em><\/li>\n\n\n\n<li><em><\/em><em>pharmacologic treatments have poor evidence but may be considered<\/em><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<ul class=\"wp-block-list\">\n<li><em><strong>Reassure<\/strong><\/em>\n<ul class=\"wp-block-list\">\n<li><em>Tics will completely remit in many children with recent-onset tics or, more likely, will cease to be noticed or to affect quality of life<\/em><em><sup>2<\/sup><\/em><\/li>\n\n\n\n<li><em>Most children with tics in isolation do not require medication<\/em><\/li>\n\n\n\n<li><em>Pharmacological treatment has poor evidence of efficacy<\/em><em><sup>6,7<\/sup><\/em><\/li>\n\n\n\n<li><em>Cognitive behavioural therapy (CBT; e.g., habit reversal training) has good evidence of efficacy<\/em><em><sup>5<\/sup><\/em><em>&nbsp;but requires high degree of engagement<\/em><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><em><strong>Support<\/strong><\/em>\n<ul class=\"wp-block-list\">\n<li><em>Provide information leaflets; e.g., &#8216;<a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Strategies-to-manage-tics.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Strategies-to-manage-tics.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Tic Tips: Strategies to help you manage your Tourette Syndrome<\/a>&#8216;<\/em><\/li>\n\n\n\n<li><em>Signpost to Tourette Scotland (lists local support groups) and<a href=\"https:\/\/www.tourettes-action.org.uk\/\" target=\"_blank\" rel=\"noreferrer noopener\">&nbsp;Tourettes Action website<\/a><\/em><\/li>\n\n\n\n<li><em>Identify co-morbidities (e.g., depression, anxiety, ADHD, Obsessive Compulsive Disorder (OCD)) and manage accordingly<\/em><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Strategies-to-manage-tics.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Strategies-to-manage-tics.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Strategies to manage tics.pdf<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/1487860486_TS-the-simple-truth-A-guide-to-TS-for-children-and-young-people.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/1487860486_TS-the-simple-truth-A-guide-to-TS-for-children-and-young-people.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">1487860486_TS&#8211;the-simple-truth&#8212;A-guide-to-TS-for-children-and-young-people.pdf<\/a>\u200b<\/p>\n\n\n\n<p><em><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/TIC-YGTSS-Clinician.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/TIC-YGTSS-Clinician.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">TIC-YGTSS-Clinician.pdf<\/a><\/em><\/p>\n\n\n\n<p><em><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/tic-disorder-leaflet.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/tic-disorder-leaflet.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">tic disorder leaflet.pdf<\/a><\/em><\/p>\n\n\n\n<p><em>Tourette Scotland &#8211;<\/em><em>&nbsp;<a href=\"https:\/\/www.tourettescotland.org\/\" target=\"_blank\" rel=\"noreferrer noopener\">www.tourettescotland.org\/<\/a>&nbsp;<\/em><\/p>\n\n\n\n<p><em>Tourettes Action &#8211;<\/em><em>&nbsp;<a href=\"https:\/\/www.tourettes-action.org.uk\/\" target=\"_blank\" rel=\"noreferrer noopener\">www.tourettes-action.org.uk\/<\/a><\/em><\/p>\n\n\n\n<p><em><sup>1<\/sup><\/em><em>American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5<\/em><em><sup>th<\/sup><\/em><em>&nbsp;edition. Arlington, VA., American Psychiatric Association, 2013.<\/em><\/p>\n\n\n\n<p><em><sup>2<\/sup><\/em><em>Black KJ, Black ER, Greene DJ, Schlaggar BL. Provisional Tic Disorder: What to tell parents when their child first starts ticcing. F1000Res. 2016;5:696. doi: 10.12688\/f1000research.8428.1.<\/em><\/p>\n\n\n\n<p><em><sup>3<\/sup><\/em><em>Khalifa N, von Knorring Al. Psychopathy in a Swedish population of school children with tic disorders. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1346-1353. [PubMed: 17075357]<\/em><\/p>\n\n\n\n<p><em><sup>4<\/sup><\/em><em>Knight T, Steeves T, Day L, Lowerison M, Jette N, Pringsheim T. Prevalence of tic disorders: a systematic review and meta-analysis. Pediatr Neurol. 2012;47:77-90. doi: 10.1016\/j.pediatrneurol.2012.05.002.<\/em><\/p>\n\n\n\n<p><em><sup>5<\/sup><\/em><em>Piacentini J, Woods DW, Scahill L, et al. Behavior Therapy for Children With Tourette Disorder: A Randomized Controlled Trial. JAMA. 2010;303(19):1929-1937. doi: 10.1001\/jama.2010.607.<\/em><\/p>\n\n\n\n<p><em><sup>6<\/sup><\/em><em>Pringsheim T, Holler-Managan Y, Okun MS, Jankovic J, Piacentini J, Cavanna AE, Martino D, M\u00fcller-Vahl K, Woods DW, Robinson M, Jarvie E, Roessner V, Oskoui M. Comprehensive systematic review summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology May 2019;92(19):907-915. doi: 10.1212\/WNL.0000000000007467.<\/em><\/p>\n\n\n\n<p><em><sup>7<\/sup><\/em><em>Weisman H, Qureshi IA, Leckman JF, Scahill L, Bloch MH. Systematic review: pharmacological treatment of tic disorders\u2014efficacy of antipsychotic and alpha-2 adrenergic agonist agents. Neurosci Biobehav Rev.<\/em><\/p>\n<\/div><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Information Prevalence DSM-5 Definition and Diagnostic Criteria1 Provisional tic disorder Persistent (chronic) motor or vocal tic disorder Tourette&rsquo;s disorder &ge;1 motor&nbsp;or&nbsp;vocal tics &ge;1 motor&nbsp;or&nbsp;vocal tics present during the illness, but not both &ge;2 motor&nbsp;and&nbsp;&ge;1 vocal tics present at some time during the illness, although not necessarily concurrently Tics present for &lt;1y since first tic onset<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":4266,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"categories":[987],"class_list":["post-4469","page","type-page","status-publish","hentry","category-https-apps-nhslothian-scot-refhelp-guidelines-ticdisordersincludingtourettessyndrome"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"NHS Lothian","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/nhs-lothian\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/paediatric\/paediatric-neurology\/https-apps-nhslothian-scot-refhelp-guidelines-ticdisordersincludingtourettessyndrome\/\" rel=\"tag\">Tic Disorders (including Tourette's Syndrome)<\/a>","rttpg_excerpt":"Information Prevalence DSM-5 Definition and Diagnostic Criteria1 Provisional tic disorder Persistent (chronic) motor or vocal tic disorder Tourette&rsquo;s disorder &ge;1 motor&nbsp;or&nbsp;vocal tics &ge;1 motor&nbsp;or&nbsp;vocal tics present during the illness, but not both &ge;2 motor&nbsp;and&nbsp;&ge;1 vocal tics present at some time during the illness, although not necessarily concurrently Tics present for &lt;1y since first tic onset","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4469","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=4469"}],"version-history":[{"count":4,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4469\/revisions"}],"predecessor-version":[{"id":15574,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4469\/revisions\/15574"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4266"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=4469"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=4469"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}