Assessment and Management of Tic Disorders in Pediatric Primary Care Settings
- 13 Downloads
Purpose of Review
Pediatricians and other primary care providers are often the first and sole healthcare clinicians of patients who present with tics. However, limited primary care pediatric training in neuropsychiatric concerns, as well as perceived lack of comfort and preparation, makes it challenging for these clinicians to confidently identify and manage tic disorders.
Current empirical findings of tic disorder management relevant to pediatric physicians, including assessment, psychoeducation, behavioral interventions, psychotropic medications, and alternative treatments are reviewed.
This article discusses neuropsychiatric and medical complexities of tic disorder assessment, with particular emphasis on differential and comorbid diagnoses. Tiered referral recommendations, based on symptom severity, impairment, and consideration of comorbid conditions, are provided. Future directions for tic management, including dissemination of evidence-based treatments of tic disorders and multidisciplinary teams within pediatric primary care settings, are included.
KeywordsTic disorders Tourette’s syndrome Pediatric primary care Pediatricians
The research reported in this publication was supported by National Institute of Mental Health K23MH113884 grant funding to Dr. Ricketts.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflicts of interest.
Human and Animal Rights and Informed Consent
All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 8.Cuenca J, Glazebrook C, Kendall T, Hedderly T, Heyman I, Jackson G, et al. Perceptions of treatment for tics among young people with Tourette syndrome and their parents: a mixed methods study. BMC Psychiatry. 2015;15:46. https://doi.org/10.1186/s12888-015-0430-0.CrossRefPubMedPubMedCentralGoogle Scholar
- 15.Müller-Vahl KR, Sambrani T, Jakubovski E. Tic disorders revisited: introduction of the term “tic spectrum disorders”. Eur Child Adolesc Psychiatry. 2019;1–7. https://doi.org/10.1007/s00787-018-01272-7.
- 19.Peterson BS, Pine DS, Cohen P, Brook JS. Prospective, longitudinal study of tic, obsessive-compulsive, and attention-deficit/hyperactivity disorders in an epidemiological sample. J Am Acad Child Adolesc Psychiatry. 2001;40:685–95. https://doi.org/10.1097/00004583-200106000-00014.CrossRefPubMedGoogle Scholar
- 24.Tourette Association of America (2018) 2018 impact survey: assessing the impact of Tourette syndrome and tic disorders on individuals and families. In: Research and medical. https://s3.amazonaws.com/tourette.org/media/20190319084932/TAA-Impact-Survey-Results-2018_Final-Jan2018_FINAL.pdf. Accessed 21 April 2019.
- 25.•• Cath DC, Hedderly T, Ludolph AG, Stern JS, Murphy T, Hartmann A, et al. European clinical guidelines for Tourette syndrome and other tic disorders. Part I: assessment. Eur Child Adolesc Psychiatry. 2011;20:155–71. https://doi.org/10.1007/s00787-011-0164-6 This report developed by a working group of the European Society for the Study of Tourette syndrome marks the first set of European clinical assessment guidelines on tic disorders and co-occurring conditions across youth and adults. CrossRefPubMedPubMedCentralGoogle Scholar
- 30.Ghosh D, Rajan PV, Das D, Datta P, Rothner AD, Erenberg G. Sleep disorders in children with Tourette syndrome. Pediatr Neurol. 2014;51:31–5. https://doi.org/10.1016/j.pediatrneurol.2014.03.017.CrossRefPubMedGoogle Scholar
- 31.Achenbach TM, Rescorla LA. The manual for the ASEBA preschool forms & profiles. Burlington: University of Vermont, Research Center for Children, Youth, and Families; 2000.Google Scholar
- 32.Achenbach TM, Rescorla L. The manual for the ASEBA school-age forms & profiles. Burlington: University of Vermont, Research Center for Children, Youth, and Families; 2001.Google Scholar
- 33.SwansonJM. Swanson, Nolan and Pelham questionnaire (SNAP). In: Online ADHD rating scales. DefiniPoint. https://www.attentionpoint.com/x_upload/media/images/snap_description_with_questions-1.pdf. Accessed 7 Jan 2019.
- 36.Barfell KSF, Snyder RR, Isaacs-Cloes KM, Garris JF, Roeckner AR, Horn PS, et al. Parent and patient perceptions of functional impairment due to Tourette syndrome: development of a shortened version of the child Tourette syndrome impairment scale. J Child Neurol. 2017;32:725–30. https://doi.org/10.1177/0883073817702782.CrossRefPubMedGoogle Scholar
- 37.Su MT, McFarlane F, Cavanna AE, Termine C, Murray I, et al. The English version of the Gilles de la Tourette syndrome—quality of life scale for children and adolescents (C&A-GTS-QOL): a validation study in the United Kingdom. J Child Neurol. 2017;32:76–83. https://doi.org/10.1177/0883073816670083.CrossRefPubMedGoogle Scholar
- 42.Conners CK. Conners comprehensive behavior rating scales. North Tonawanda: Multi-Health Systems Inc.; 2014.Google Scholar
- 43.Piacentini J, Langley A, Roblek T. Cognitive behavioral treatment of childhood OCD: it’s only a false alarm, therapist guide. New York: Oxford University Press; 2007.Google Scholar
- 45.Storch EA, Khanna M, Merlo LJ, Loew BA, Franklin M, Reid JM, et al. Children’s Florida obsessive compulsive inventory: psychometric properties and feasibility of a self-report measure of obsessive-compulsive symptoms in youth. Child Psychiatry Hum Dev. 2009;40:467–83. https://doi.org/10.1007/s10578-009-0138-9.CrossRefPubMedGoogle Scholar
- 46.Birmaher B, Khetarpal S, Brent D, Cully M, Balach L, Kaufman J, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry. 1997;36:545–53. https://doi.org/10.1097/00004583-199704000-00018.CrossRefPubMedGoogle Scholar
- 47.Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry. 1999;38:1230–6. https://doi.org/10.1097/00004583-199910000-00011.CrossRefPubMedGoogle Scholar
- 48.March JS. Manual for the Multidimensional Anxiety Scale for Children (MASC). 2nd ed. North Tonawanda: Multi-Health Systems Inc; 2012.Google Scholar
- 49.Kovacs M. Manual for Children’s Depression Inventory. North Tonawanda: Multi-Health Systems, Inc; 2010.Google Scholar
- 50.Ricketts EJ, McGuire JF, Chang S, Bose D, Rasch MM, Woods DW, et al. Benchmarking treatment response in Tourette’s disorder: a psychometric evaluation and signal detection analysis of the parent tic questionnaire. Behav Ther. 2018;49:46–56. https://doi.org/10.1016/j.beth.2017.05.006.CrossRefPubMedGoogle Scholar
- 52.• Leckman JF, Riddle MA, Hardin MT, Ort SI, Swartz KL, Stevenson J, et al. The Yale Global Tic Severity Scale: initial testing of a clinician-rated scale of tic severity. J Am Acad Child Adolesc Psychiatry. 1989;28:566–73. https://doi.org/10.1097/00004583-198907000-00015 This study reports on psychometric properties for a clinician-rated interview of tic symptoms, now considered a gold-standard measure of tic severity. CrossRefPubMedGoogle Scholar
- 55.Lewin AB, Park JM, Storch EA. Obsessive-compulsive disorder in children and adolescents. In: Vasa RA, Roy AK, editors. Pediatric anxiety disorders: a clinical guide. New York: Humana Press; 2013.Google Scholar
- 56.Freeman RD. Stereotypic movement disorder. In: Freeman RD, editor. Tics and Tourette syndrome. London: Mac Keith Press; 2015.Google Scholar
- 60.• Mansueto CS, Keuler DJ. Tic or compulsion?: it’s Tourettic OCD. Behav Modif. 2005;29:784–99. https://doi.org/10.1177/0145445505279261 This paper contributed to the case conceptualization of patients with Tourettic OCD as well as treatment recommendations for these patients. CrossRefPubMedGoogle Scholar
- 61.• Murphy TK, Lewin AB, Storch EA, Stock S, AACAP-CQI. Practice parameter for the assessment and treatment of children and adolescents with tic disorders. J Am Acad Child Adolesc Psychiatry. 2013;52:1341–59. https://doi.org/10.1016/j.jaac.2013.09.015 This reports on the American Academy of Child and Adolescent Psychiatry’s assessment and treatment guidelines for children and adolescents with tic disorders. CrossRefPubMedGoogle Scholar
- 62.Hawley JS, Johnson MA, Dennison DH. Tourette syndrome. In: Feld LG, Mahan JD, editors. Succinct pediatrics: evaluation and management for newborn, genetic, neurologic, and developmental-behavioral disorders. American Academy of Pediatrics: Elk Grove Village; 2018.Google Scholar
- 63.•• Swedo SE, Leonard HL, Garvey M, Mittleman B, Allen AJ, Perlmutter S, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: Clinical description of the first 50 cases. Am J Psychiatry. 1998;155:264–71. https://doi.org/10.1176/ajp.155.2.264 This study provides a description of the first 50 children meeting the working diagnostic criteria for PANDAS, a discussion of clinical implications and suggests a model of pathogenesis. CrossRefPubMedGoogle Scholar
- 64.• Swedo SE, Leckman JF, Rose NR. From research subgroup to clinical syndrome: modifying the PANDAS criteria to describe PANS (pediatric acute-onset neuropsychiatric syndrome). Pediatr Therapeut. 2012;2:113. https://doi.org/10.4172/2161-0665.1000113 This report is a summary of a 2010 workshop assembled to address the limitations of PANDAS diagnostic criteria and revise them, yielding PANS. CrossRefGoogle Scholar
- 65.• Chang K, Frankovich J, Cooperstock M, Cunningham MW, Latimer ME, Murphy TK, et al. Clinical evaluation of youth with pediatric acute-onset neuropsychiatric syndrome (PANS): recommendations from the 2013 PANS consensus conference. J Child Adolesc Psychopharmacol. 2015;25:3–13. https://doi.org/10.1089/cap.2014.0084 This report summarizes proceedings at the first PANS Consensus Conference held in 2013. It provides recommendations for diagnostic evaluation of children presenting with PANS. CrossRefPubMedPubMedCentralGoogle Scholar
- 70.• Verdellen C, van de Griendt J, Hartmann A, Murphy T, ESSTS Guidelines Group. European clinical guidelines for Tourette syndrome and other tic disorders. Part III: behavioural and psychosocial interventions. Eur Child Adolesc Psychiatry. 2011;20:197–207. https://doi.org/10.1007/s00787-011-0167-3 This report provides guidelines by a working group of the European Society for the Study of Tourette syndrome on behavioral and psychosocial treatment of tic disorders and recommends behavior therapy as a first-line intervention for patients with tics. CrossRefPubMedGoogle Scholar
- 73.• Conelea CA, Woods DW, Zinner SH, Budman C, Murphy T, Scahill LD, et al. Exploring the impact of chronic tic disorders on youth: results from the Tourette Syndrome Impact Survey. Child Psychiatry Hum Dev. 2011;42:219–42. https://doi.org/10.1007/s10578-010-0211-4 This survey evaluated tic-related functional impairment in one of the largest samples of parents and their children with chronic tic disorders. CrossRefPubMedGoogle Scholar
- 76.Wu MS, McGuire JF. Psychoeducation about tic disorders and treatment. In: McGuire JF, Murphy TK, Piacentini J, Storch EA, editors. The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. London: Academic Press; 2018. p. 21–41.Google Scholar
- 78.• Woods DW, Piacentini JC, Chang SW, Deckersbach T, Ginsburg GS, Peterson AL, et al. Managing Tourette syndrome: a behavioral intervention for children and adults, therapist guide. New York: Oxford University Press; 2008. This book is the therapist manual for comprehensive behavioral intervention for tics stemming from the randomized, controlled trial of behavior therapy for tics. CrossRefGoogle Scholar
- 79.Lyon GJ, Samar SM, Conelea C, Trujillo MR, Lipinski CM, Bauer CC, et al. Testing tic suppression: comparing the effects of dexmethylphenidate to no medication in children and adolescents with attention-deficit/hyperactivity disorder and Tourette’s disorder. J Child Adolesc Psychopharmacol. 2010;20:283–9. https://doi.org/10.1089/cap.2010.0032.CrossRefPubMedPubMedCentralGoogle Scholar
- 80.Chorpita BF, Weisz JR. MATCH-ADTC: modular approach to therapy for children with anxiety, depression, trauma, or conduct problems. Satellite Beach: PracticeWise; 2009.Google Scholar
- 82.Specht MW, Edwards KR, Perry-Parrish C, Amatya K. Brief trans-diagnostic parent training: a strengths-based, parent-centered treatment for youth with Tourette syndrome. In: McGuire JF, Murphy TK, Piacentini J, Storch EA, editors. The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. London: Academic Press; 2018. p. 225–53.Google Scholar
- 83.Lebowitz ER, Marin C, Martino A, Shimshoni Y, Silverman WK. Parent-based treatment as efficacious as cognitive behavioral therapy for childhood anxiety: a randomized noninferiority study of supportive parenting for anxious childhood emotions. J Am Acad Child Adolesc Psychiatry. 2019. https://doi.org/10.1016/j.jaac.2019.02.014.
- 86.Barkley RA. Defiant children: a clinician’s manual for assessment and parent training. 3rd ed. New York: Guilford Press; 2013.Google Scholar
- 87.Kazdin AE. Parent management training: treatment for oppositional, aggressive, and antisocial behavior in children and adolescents. New York: Oxford University Press; 2005.Google Scholar
- 88.Eyberg SM, Funderburk BW. Parent–child interaction therapy protocol. PCIT International: Gainesville; 2011.Google Scholar
- 89.Peris TS, Rozenman MS, Sugar CA, McCracken JT, Piacentini J. Targeted family intervention for complex cases of pediatric obsessive-compulsive disorder: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2017;56:1034–42. https://doi.org/10.1016/j.jaac.2017.10.008.CrossRefPubMedPubMedCentralGoogle Scholar
- 93.Ginsburg GS, Kingery JN. Management of familial issues in persons with Tourette syndrome. In: Woods DW, Piacentini J, Walkup JT, editors. Treating Tourette syndrome and tic disorders: a guide for practitioners. New York: Guilford Press; 2007.Google Scholar
- 94.Capriotti MR, Piacentini JC, Himle MB, Ricketts EJ, Espil FM, Lee HJ, et al. Assessing environmental consequences of ticcing in youth with chronic tic disorders: the tic accommodation and reactions scale. Child Health Care. 2015;44:205–20. https://doi.org/10.1080/02739615.2014.948164.CrossRefPubMedGoogle Scholar
- 95.•• Azrin NH, Nunn RG. Habit-reversal: a method of eliminating nervous habits and tics. Behav Res Ther. 1973;11:619–28. https://doi.org/10.1016/0005-7967(73)90119-8 This report describes habit reversal training for body-focused repetitive behaviors and tics in a systematic manualized style. This work is the basis of current behavior therapy for tics. CrossRefPubMedGoogle Scholar
- 96.• Azrin NH, Peterson AL. Treatment of Tourette syndrome by habit reversal: a waiting-list control group comparison. Behav Ther. 1990;21:305–18. https://doi.org/10.1016/S0005-7894(05)80333-8 This study also informed current iterations of behavior therapy for tics with its inclusion of relaxation training. CrossRefGoogle Scholar
- 97.•• Piacentini J, Woods DW, Scahill L, Wilhelm S, Peterson AL, Chang S, et al. Behavior therapy for children with Tourette disorder: a randomized controlled trial. JAMA. 2010;303:1929–37. https://doi.org/10.1001/jama.2010.607 This is the largest randomized, controlled trial showing support for the efficacy of behavior therapy for Tourette’s disorder in youth. CrossRefPubMedPubMedCentralGoogle Scholar
- 98.•• Wilhelm S, Peterson AL, Piacentini J, Woods DW, Deckersbach T, Sukhodolsky DG, et al. Randomized trial of behavior therapy for adults with Tourette Syndrome. Arch Gen Psychiatry. 2012;69:795–803. https://doi.org/10.1001/archgenpsychiatry.2011.1528 This is the largest randomized, controlled trial supporting the efficacy of behavior therapy for Tourette’s disorder in adults. CrossRefPubMedPubMedCentralGoogle Scholar
- 99.Ricketts EJ, Bauer CC. Habit reversal training. In: McGuire JF, Murphy TK, Piacentini J, Storch EA, editors. The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. London: Academic Press; 2018. p. 43–70.Google Scholar
- 102.Ricketts EJ, Goetz AR, Capriotti MR, Bauer CC, Brei NG, Himle MB, et al. A randomized waitlist-controlled pilot trial of voice over Internet protocol-delivered behavior therapy for youth with chronic tic disorders. J Telemed Telecare. 2016;22:153–62. https://doi.org/10.1177/1357633X15593192.CrossRefPubMedGoogle Scholar
- 107.Hoogduin K, Verdellen C, Cath D. Exposure and response prevention in the treatment of Gilles de la Tourette’s syndrome: four case studies. Clin Psychol Psychotherapy. 1997;4:125–35. https://doi.org/10.1002/(SICI)1099-0879(199706)4:2<125::AID-CPP125>3.0.CO;2-Z.CrossRefGoogle Scholar
- 110.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;37:1162–71. https://doi.org/10.1016/j.neubiorev.2012.09.008.CrossRefPubMedGoogle Scholar
- 115.The Pediatric OCD Treatment Study (POTS) Team. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the pediatric OCD treatment study (POTS) randomized controlled trial. JAMA. 2004;292:1969–76. https://doi.org/10.1001/jama.292.16.1969.CrossRefGoogle Scholar