Tics, Twitches and Tourette's: When to Worry and What to Do

I'm Holly Wehmins, and this is Pediatrics Now, cases, updates, and discussions for the busy pediatric practitioner.

Click on the link in this podcast for free credit that includes CME, MOC, or ethics credit, depending on our topic or podcast. I'm so excited today because joining us here in the podcast studio is Dr. Sheldon Gross, who has been practicing neurology for 42 years now. That's correct. Dr. Gross, thank you so much for being here in the podcast studio. I've been looking forward to this, Holly. And off the top, I want to mention also thank you for curing my migraine headaches.

I had migraine headaches for more than 20 years, and you gave me some great advice, and it was about the headache diet, and it really works. I mean, it was incredible. I'm delighted, and I wish I met you 20 years ago. Thank you so much. And we do have a podcast episode in our news feed about the headache diet in case you're interested and want to talk to your patients about this. And we have a version on our Pediatrics Now for Parents podcast, the sister podcast. So we have that episode as well.

So today we're talking about ticks and twitches. Dr. Gross, for our listeners, can you start by explaining the difference between a tick and a twitch? Community pediatricians see this a lot. Holly, when people say tics, what they're referring to is what I would call a nervous mannerism, just a nervous habit that people have. Probably the most common one is eye blinking. You may have friends that just have this habit of nervously blinking their eyes.

It can be either movement, it can be making noises or making sounds. It can take a hundred different forms. And in terms of twits, that's a much more nonspecific term. A twits could be one of 20 different things. A tick is something that's very specific for one particular condition, which we're going to talk about today. Yes, so let's dive in. So when parents describe eye blinking or throat clearing, what helps you decide whether it's a motor tick versus something else?

Well, a motor tick is something that kids will do over and over again. When you ask them, why are you doing that? They typically say either, I don't know, or they will say, I just have this urge to do this, and I can't control it. They're awake during this. They're alert during this. Sometimes they know they're doing it. Sometimes they don't know they're doing it. There's one thing I've learned to do, which is amazingly simple. I'll ask people to repeat and show me what it is that they do.

And for patients with tics, they can say, oh, I do this. And then they'll show you the way they posture their hand or wiggle their nose or whatever. And for other conditions, she can't do that. A tick is totally harmless. And I've seen so many families that come in really anxious about this, really concerned that their child has some horrible condition. And once I determine that these are ticks, the very first thing I do is tell them their child is fine. This is not a dangerous problem.

This doesn't cause any problem at all. In fact, what I see happen, Holly, is I see a terrible cycle develop. A child will be having tics. The family is incredibly anxious. The child picks up on the anxiety, and that makes the child anxious, which in turn makes the tics worse. So the first thing I have to do is break that cycle, convince people that this is not a dangerous problem, that their child is healthy, and I really tell them

as much as possible just to try to ignore it. Don't comment on it at all. I'll never forget one father that had a stopwatch and was timing his child to see how many tics he had in one minute. Really? And that's the absolute worst thing you could do. So there's a lot of things that we can accomplish with very little effort.

And it's hard as a parent not to do that. I know with my daughter, when she's having an ear infection and she's not hearing as well, and I have to try to stop myself from asking her every hour, like, are you hearing better now? How is it going? And then that creates this anxiety. You know what I tell the medical students? So I say, well, take patience. Once I'm sure what I'm dealing with, I'll spend five minutes with the patient and 45 minutes with the parents.

Because you really have to get at that anxiety in order to make any progress at all. Do we know what causes tics? Well, we probably think that in many cases there's a genetic component. I can tell you that there is a small Mennonite community in Alberta, Canada. One of the founding fathers had Tourette's syndrome, and there was a lot of inbreeding. So now 25% of the people there were a descendant of this one individual, and 25% of that community has Tourette's syndrome. them.

So we know that in some instances there's a genetic component. In other instances, we really don't know. What we do know is what makes it worse. And so often that's the first thing I'll go through with families. I don't go right to medicine. I'll say, let's talk about some of the things in your child's life or environment that may be making this worse or maybe even causing it in the first place. Video games? Well, not necessarily video games, although maybe. I've written down a list of things.

Without any question, the most common thing that makes ticks worse is stress. And that is much more common than just about anything else. So once I've determined a child is having ticks, I'll say, what is your child's life like? What's going on? Is he in a new school? I've had patients that were bullied at school and developed ticks or worsening ticks. Sometimes there's stress in the family. I've had kids where the parents are going through a separation or a divorce.

That type of stress often aggravates tics or can even cause tics from the very start. And then once I've gone through that, I start asking other questions. Specifically, are there any other medicines that the patient is taking? There's one medicine in particular that is famous for causing tics, and those are the stimulants. Medicines for ADHD such as Ritalin or Adderall or Vyvanse, you may have heard of all these. Yes. They can be very effective for ADHD, but they can also make ticks much worse.

So if I have a patient who's got ADHD, and there's a very strong relationship between these two, ticks and ADHD, the two occur very commonly in the same patient. I do everything I can to avoid using stimulants. And if they're already on a stimulant, I'll suggest let's get you off of a stimulant and use a different type of a medicine. And along with stimulants, caffeine fits right in there. So I'll tell kids, try to limit or even eliminate how much caffeine you drink.

Other things that can do it, we know that a lack of rest or inefficient sleep can result in tics or worsening tics. And getting back to what I said initially, profound anxiety and depression can all do this. So before I even mention medicine, I go through all these different aspects because I think fewer than 50% of my patients with Tourette's syndrome go on medicine.

Just like I helped you with your migraine with diet, there's a lot you can do to help patients with Tourette's syndrome and tics that does not require medicine.

And talking about the anxiety and depression, I know we're going to be talking today about how psychiatry and neurology overlaps, and then that's clearly an area where there's this overlap, and this, as we all know, there's this epidemic right now of anxiety and depression. Well, you're exactly correct, and I like to tell the students and interns that come through and work with me.

I've had patients with Tourette's syndrome or tics, and we'll talk about Tourette's syndrome in just a moment, that actually never come under control until we do something about stress and anxiety and possible depression. Perhaps that means working with a family therapist. Perhaps it means going on medicine, not for tics, but for stress and anxiety. And I try to convince all the students, you can attack a problem two different ways.

You can give medicine for the problem itself, in this case, tics, or you can try to attack the underlying factors that are making the tics worse. And that's what we were just talking about. And in fact, a lot of my patients really respond beautifully to medicine for stress and anxiety, and you don't have to give them medicine for tics. So there's not evidence, as far as we know, though, showing our. Increasing time spent in front of screens, that that's causing it, it's probably not helping it?

Or do you want to say anything about that? I would say it depends on what you're watching. I don't think the video by itself does anything. But if you're watching something that results in increased stress or makes a child anxious or even depressed, then yes, it can affect tics. But if you're watching something otherwise, then I think it's very questionable whether that matters or not.

I would imagine it's also difficult in school for kids if they're having a tick and then their friends, classmates are then responding to the tick in some way. That's not helping the anxiety. And that varies immensely from one person to the next. Let me take just a moment and talk about what Tourette's syndrome is. Yes, when do we worry about Tourette's? First of all, Tourette's syndrome is not a separate type of disease like cancer or diabetes.

Tics comes in this huge spectrum all the way from very, very mild to overwhelmingly severe. And a group of individuals got together and said, let's take this subset of tic patients and let's call this Tourette syndrome or initially Gilles de la Tourette syndrome. Now people just call it Tourette syndrome. And it's really three different things that you have to satisfy.

You have to have the presence of motor tics, which is movement, whether that's eye blinking or wiggling your nose or making some type of arm and shoulder and neck shrug or something of that nature. You also have to have vocal tics, which means not necessarily saying words, but making noises, snorting, coughing. Any kind of a noise is considered a vocal tic. And the last requirement is it has to be there for at least a year.

So if you have the patient who has motor tics, vocal tics for longer than a year, you would say it's Tourette's syndrome. But I have to spend time with the family to explain, I'm not telling you anything that you don't already know. You already know that this has been here longer than a year. You already know that it involves both movement as well as speech. Some people think Tourette's is a separate disease or a separate entity, and I try to dispel that.

That's the first thing. Now, in terms of what you do, that depends entirely on how the child is affected. I can tell you that many times I have families come in horribly upset, horribly anxious. And then I'll look at the kid and I'll say, do these bother you? And they'll say, no, they don't bother me at all. I do this, but I don't care. No one really bugs me. I'm a happy guy.

So what do you do in that case? You again, spend 45 minutes with the family trying to convince them they have a healthy child, leave him alone.

I try to say in the nicest way possible, go away and don't come back. In other words, we don't need to do anything right now. So when, and also when you say we don't need to do anything right now, but what if they don't go away in a year? It eventually boils down to how is the child affected by this? Are these ticks intrusive in his life. And usually, this is going to sound very unscientific, but what I do is I basically look at the child and say, would you like to take medicine for this?

And if he says yes, then I talk about medicine. But I try to not do it unless I'm sure it's making a difference because so many people have tics and it just doesn't bother them at all. But if a child says, I'm feeling very self-conscious, I'm feeling isolated, my friends are teasing me or anything like that. And if he says, yes, I want to take medicine, that's when we talk about the option of medicine.

So is what you're saying, Sheldon, is it a form of Tourette's, but a very mild form if a child has for a short time even a tick? Or is that way off? It has to be at least a year. Okay, otherwise it's not. It's just you would call it a tick disorder. You would not use the term Tourette's syndrome. Okay. And even before medicine, there's other things I'll try first.

There's a program here at UT Health in San Antonio where they try to train children how to control ticks on their own without the use of medicine. Or if it's a very disturbing, distracting tick, like making a loud whooping noise or something, which in a classroom, teachers can get upset about that. They try to teach them how to substitute something else like wiggling their finger underneath the desk or something that is not disruptive.

So typically in most instances, if it's an option, I'll try to get them to go to this program first to see if they can find a non-medical way of helping a child control ticks. Is part of that because there's so much sitting involved in school all day? Well, possibly. Possibly. And a lot of it could be from a thousand different factors. It could be a child with learning disabilities who's concerned he's going to fail three different classes.

It can be someone who's moved from another town and he's trying to make friends and having a tough time of it. It could be someone who's bullied. I mean, there's really an endless list of things in school that might trigger ticks. So when should a pediatrician refer to neurology if their patient is coming in with a tick?

Well, if the patient says, and if the family says, our son is miserable and wants to take medicine, and if the pediatrician is not comfortable himself, that's when he should refer either to a neurologist or sometimes child psychiatrists take care of this as well. But a lot of pediatricians will treat this themselves if they're comfortable with the medicine. Yes. So can you talk about that a bit? What can be treated in the office? What would your advice be?

Well, if we've done all those other things, if we've determined this is a child where the tics really aren't and the Tourette's is really having a negative effect on him. If you've tried this program I told you about that it's not working, and if he and the family are both saying we want to take medicine for this, then you can start with very simple things that I think a lot of pediatricians are already using.

There is a medicine called guanfacine, which is commonly used to treat attention deficit disorder. Guanfacine is also, in many instances, very effective at suppressing ticks. There's another medicine, clonidine, which is similar to guanfacine. It also suppresses ticks. And there are other medicines, what we call the dopamine blockers, medicines like Abilify, Risperdal.

Those medicines can be effective. And then there's another medicine that's actually a seizure in a migraine medicine called Topamax or Topiramate, where there's more and more interest in using that to suppress tics as well.

And since we're talking about treatment. I also try to tell the medical students, whenever you're starting a treatment plan, talk about your goals right off the bat so the family knows what it is you're trying to accomplish. For patients with Tourette's, you rarely get them completely free of tics. That typically does not happen, and that's not really my goal. My goal is to get to where the tics are not intrusive in his life, to get to where the tics are no longer a real problem for him.

Is it the same medications you're mentioning for tics and tics caused by Tourette's? Yes, you would use the same types of medicines. And that program I told you about, we call it CBIT, the Cognitive Behavioral Intervention Therapy. That program works for patients that have full-blown Tourette's as well as people that have just a plain simple tic disorder. And so for our listeners in the San Antonio area, can you tell us more about where that is?

It's here in San Antonio. I would have to look at my telephone to get the phone number. Well, we could put a link into it. And it's referred to as the Tourette's Syndrome Program. How common are transient tics in children, and how often do they resolve on their own versus progress to a chronic condition? They're very common. In fact, of all the types of movement disorders that we see in child neurology, without any question, tics are the most common type of movement disorder.

And whoever sent in that question, that's a very good one, because many times ticks do resolve, especially if they're related to some severe stress or anxiety, and you're able to somehow fix whatever it is that's the root of that. Or if they're on a medicine like Ritalin, and you take them off, a lot of the times they'll go away, and sometimes they'll just go away spontaneously, and you don't know why. But the answer is yes, they do often go away by themselves.

Sheldon, is there an age window when you most often see transient tics? I tend to see tics probably, initially, probably, I would take a guess between age five all the way through adolescence. They can start really any time at all. And probably there have been cases where it's younger than age five. So it's a very wide range. And I don't think there's any specific hard and fast rule for how old you have to be before you have tics.

So Sheldon, there's often an overlap between neurology and psychiatry when it comes to tics. How do you approach distinguishing between neurological and psychiatric causes in your practice? That is such a great question, and that leads into the second part of our conversation today. I'm trying to start a new clinic here at UT. I'm trying to start a clinic where we use the term dual diagnosis, which means you have a neurological diagnosis plus a psychiatric diagnosis.

Because I have so many patients that have migraine and depression, or they have seizures and bipolar syndrome, or they have something else with a horribly chaotic, anxiety-provoking family situation. And sometimes it's very difficult to separate what is psychiatric and what is neurological. Those two so rapidly or so frequently are all mixed in together.

And if you have any question, you have to either refer to either a family therapist or if you think someone needs to be placed on medicine, you try to get a psychiatrist involved. But let me switch over now for just a second, because I like to tell people that all sorts of talks start out with some type of seed. Something plants an idea in your head or an experience that. Affects you and makes you want to give a talk about something.

Before I give this talk about overlap between neurology and psychiatry, I've had two experiences that affected me. One experience was a call from an ER doctor almost apologetically saying, I've got this teenage girl here with classic panic attacks, and the family's insisting on going to see a neurologist. I feel like I'm wasting your time, but would you be willing to see this patient? So I said, fine. And she came and I heard about her symptoms and it sounded like classic panic attacks.

But because they went to the trouble to come and see me, I did the EEG. And lo and behold, she had seizure discharges coming from her left temporal lobe. So what people had been describing as panic attacks were, in fact, a form of temporal lobe seizure. Wow. I put her on seizure medicine, and that was the last episode she ever had.

I never forgot that. That's amazing. And then my second seed that got me interested in this was when I was asked to see a patient, a teenage boy, who arrived in the emergency room floridly psychotic, hallucinating, agitated, not making any sense, with no history whatsoever of previous psychiatric illnesses. And I gave him medicine the next day he was back to normal. So as I was talking to him, I said, what's the last thing you remember?

He said, well, I remember having a severe headache and seeing purple spots in my vision. This was a migraine patient. And as I've delved into this in greater detail, there is something called migraine psychosis. A migraine can either cause confusional episodes where you may be disoriented and you may not know where you are or make sense, and that can escalate into full-blown psychosis. So what appeared to be acute psychosis was, in fact, a migraine disorder.

And I gave him—we spoke about the same dietary things, and I gave him medicine. He never had another episode again.

Those two experiences really had an effect on me. It made me realize how a neurological condition can really present with psychiatric symptoms. What are the red flags when a family comes in for their child having what could be tics or twitches, but it really could be a seizure? Let me first of all say I've had several patients that were referred to me for tics and in fact did end up with seizures.

First of all, if someone comes in with multiple different habits, wiggling their nose, making noises, blinking their eyes, that's not the type of patient you have to worry about. That's fairly definite tics and probable Tourette syndrome. And again, I'll just tell you about patients I've seen. A tic can involve unusual rolling of the eyes or different eye movements.

That's when I'll pull out the question, show me what it looks like, and if they just do the exact same thing, that's much more suggestive of a tic. I had one patient I almost sent out of my office with a diagnosis of tics. He had unusual eye movements, but they always went to one side. And I sit there and watched him. The eye movements looked like them IP ticks, but he only went to the left. They never went to the right.

And I thought I was going to waste their money, so I said, let me do an EEG. And again, lo and behold, he had seizure discharges. That patient ended up with a large cyst in his brain and had to have surgery. And I almost sent him out of the office with the diagnosis of ticks. I've had other patients where a tick can be a sudden jerk, a jerk of the shoulders, a jerk of the arms. And there's a type of a seizure called a myoclonic seizure that can look just like that.

So what I would tell people is, if there's any question in your mind, certainly if people say, yeah, he'll do these and he's sleepy and tired afterwards, that's not a tick. If anyone has any of those symptoms after it's over, that's much more likely to be a seizure. If it's something that they cannot easily reproduce for you, that's much more likely to be a seizure.

If there's any pre-existing history, if there's a family history of epilepsy, if the patient has had a serious traumatic brain injury or if he's had an infection like meningitis or encephalitis, if the patient has a genetic condition such as Down syndrome or other genetic conditions where we know or autism, autistic patients have a very high incidence of epilepsy. In all those instances, I would recommend they be referred to a neurologist and very likely have an EEG done.

And we have a Grand Rounds talk by Dr. Mario Fierro on autism that was just released that's in our Pediatrics Now news feed. I heard it, and that was a superb presentation. He did such a great job.

Sheldon, can anxiety or obsessive-compulsive behaviors mimic or exacerbate tics? I know you've mentioned this earlier in the interview, but what clues tell us it's stress-related versus a primary movement disorder? Sometimes there's no substitute for talking to people, Holly. You just have to talk to people. And you just have to explore and probe and dig, maybe get some feedback from teachers, talk to their parents. I'm not sure you can tell just by looking at people what is induced by stress.

But you bring up a very interesting point, which is, what are some of the other conditions that can be associated with tics or associated with Tourette's syndrome? I've already said that ADHD is much more common in patients with tics than in the general population. But probably the second most common thing is obsessive-compulsive disorder. So rather than saying, is this, when people ask me, do I have Tourette's syndrome or do I have obsessive-compulsive disorder, the answer is yes.

Because people have both. And when you think about it, what is the difference between someone having an urge to roll his eyes a certain way versus having an urge to take two steps forward and two steps backward? One we would call a tick, one we would call OCD. I think we're talking about different parts of the spectrum. So obsessive-compulsive disorder is very commonly seen in patients with Tourette's syndrome.

And I would add other things commonly seen, depression, anxiety, bipolar syndrome, pretty much the whole list of things that can occur in child psychiatry occur more frequently in patients with Tourette's syndrome. This is all so insightful.

Dr. Sheldon Gross with Pediatric Neurology here at UT Health and University Hospital, thank you so much for being here today on Pediatrics Now. This has been wonderful. Well, let me put in one more plug. Sure. There's six of us. I'm the weakest link. You're humbled. The other five are younger than I am, incredibly bright, very interested in getting involved in our community. Some have already been here for 10 or 15 years. some are brand new right out of their training program.

Part of why I love this job so much is the other five child neurologists are wonderful people and superb clinicians. I'm very happy to be associated with this type of group. And I know you'd love seeing patients and you're also very humble and highly experienced and knowledgeable. Dr. Sheldon Gross, don't forget to click on the link in this podcast for free credit that may include CME, MOC, or ethics credit.

Pediatrics Now is brought to you by the Department of Pediatrics at UT Health San Antonio and.