Learning Objectives
By the end of this section, you will be able to:
- Describe diagnosis of tic disorder and Tourette syndrome
- Understand treatment options and the nurse’s role in treatment of children with tic disorder and Tourette syndrome
- Identify resources for information and support
Tourette syndrome (TS) and other tic disorders affect approximately 1 percent of school-aged children in the United States (Tourette Association of America, n.d.). Tics are sudden twitches, movements, or sounds that occur repeatedly in a person who is unable to stop their body from doing these actions. There are two types of tics: motor and vocal. Motor tics are movements of the body, such as blinking, shrugging the shoulders, or jerking an arm. Vocal tics are sounds that a person makes with their voice, such as grunting, humming, clearing the throat, or yelling out a word or phrase. Although the media often portray people with TS as involuntarily shouting out swear words (i.e., coprolalia) or constantly repeating the words of other people (i.e., echolalia), these symptoms are rare (CDC, 2021e).
Diagnostic Criteria for Tic Disorder and Tourette Syndrome
A tic disorder causes a person to uncontrollably twitch, move, or make sounds. The first symptoms are often motor tics that occur in the head and neck area. Tics are often worse during times that are stressful or exciting and tend to improve when a person is calm or focused on an activity (CDC, 2021e). Tourette syndrome (TS) tics typically begin when a child is five to ten years old. According to the CDC (2023g), diagnosis of Tourette syndrome occurs when a person has two or more motor tics and at least one vocal tic that have lasted at least a year and began prior to the age of eighteen years old. The symptoms must not be related to any other medical condition.
In most cases, tics decrease during adolescence and early adulthood and sometimes disappear entirely. But many people with TS experience tics into adulthood and, in some cases, tics can become worse during adulthood (CDC, 2021e). Tics are typically mild and do not require treatment, but it is essential to educate the individual and others about TS and provide appropriate support across all settings (e.g., school, work, and home). Behavioral treatment or medication may become necessary when tics become problematic or interfere with daily functioning (Tourette Association of America, n.d.). The DSM-5 includes three types of tic disorders: Tourette syndrome, persistent motor or vocal tic disorder, and provisional tic disorder (CDC, 2023f).
Movements
All three types of tic disorders can have motor tics present (CDC, 2023f). In persistent motor or vocal tic disorder, the individual has either motor or vocal tics (but not both) for at least one year (CDC, 2023f). In provisional tic disorder, the individual has one or the other or both but symptoms must be less than a year. Tourette syndrome must have two or more motor tics and a vocal tic for at least a year. Movements include blinking, shrugging, and twitching.
Vocalizations
Vocalizations always occur in Tourette syndrome and may occur in persistent motor and vocal tic disorder and provisional tic disorder. Vocalizations include clearing the throat, humming, and/or yelling a phrase or word, sometimes an obscenity (CDC, 2023f). Despite its portrayal in media, coprolalia (using inappropriate language) only occurs in one in ten people who have Tourette (CDC, 2023g).
Treatment
There is no known cure for tic disorders, but there are medications and therapies available to reduce the tics. Parents should be made aware that, for some children taking stimulant medication for ADHD, tics are a possible side effect (Nam et al., 2022). Nurses can educate parents on support systems that are available in the community to help them feel less alone and able to provide comfort and support to their children.
Medications and Comprehensive Behavioral Intervention for Tics
Both medications and behavioral interventions for tics have been found to be helpful in reducing tics. Therapies available include Comprehensive Behavioral Intervention Therapy (CBIT); psychotherapy to help with accompanying disorders, such as anxiety, depression, and ADHD; and deep brain stimulation (DBS). CBIT entails creating awareness of the tics and tic triggers, choosing a different behavior to replace the tics, and figuring out environments and stressors that increase tics and altering them. This form of therapy includes education, relaxation training, and behavioral rewards to the person with tics. CBIT has been shown to improve tics and offers long-term progress (Frey & Malaty, 2022). When a person has severe tics that are not responding to any other type of treatment, DBS is an option in which a battery-operated device is implanted into the person’s brain. This device gives electrical stimulation to the targeted area of the brain that controls movement (Mayo Clinic, 2018).
Some of the medications used to treat tics include antipsychotics, such as haloperidol (Haldol), risperidone (Risperdal), pimozide (Orap), and aripiprazole (Abilify). The potential side effects of weight gain and involuntary movements (Mayo Clinic, 2018) vary. Botox (botulinum) injections administered to an affected muscle can reduce a motor or vocal tic. Stimulant medications used for ADHD, such as methylphenidate (Ritalin and Metadate CD), can be used to increase concentration (but in some people with Tourette syndrome, this will also increase their tics). Antidepressants, such as fluoxetine (Prozac), assist with feelings of sadness or anxiety. And, it has been recently found that topiramate (Topamax), an anti-seizure medication, helps some people with Tourette syndrome (Mayo Clinic, 2018).
Clonidine and guanfacine may be used to stimulate alpha2 adrenergic receptors in the brain, though these medications may be sedating. Also, used outside the United States, benzamides are dopamine receptor blocking agents with fewer side effects. These include tiapride, sulpiride, and amisulpride (Frey & Malaty, 2022).
Link to Learning
View this website for valuable information on tics and Tourette syndrome from Cincinnati Children’s Hospital.
Nurse’s Role
Nurses support clients and their families through diagnosis, treatment, and management of tic disorders. Nurses can educate parents on psychosocial development in their children and the way their focus changes from family to school to their social circles once they become teenagers (Lee, 2022). Nurses can also teach parents ways to educate their children on tic management for long-term care. Learning how to cope with the effects of tics, physically, educationally, and emotionally are other areas in which a nurse can assist the family (Lee, 2022). The school nurse can be a source of support to the student by giving them a safe space to display their tics, educating staff about Tourette syndrome, and being aware of the medications that the student is taking.
Community Services/Information Resources
The Tourette Association of America offers resources to train teens to advocate for those with Tourette and tic disorders, while educating the public about these conditions (CDC, 2023g). The teen can download a guide to the disorder to access more information about the illness, navigating school and social situations, and becoming an ambassador to others. The website also contains a page dedicated to resources listed in A–Z format for individuals, parents, and professionals.
Schools can work with faculty and parents to set up an individualized education program (IEP) to support the child’s academic needs while also educating them on how to cope with this illness. The IEP might include items such as using worksheets that require minimal writing or allowing the student to leave the classroom two to three minutes early when moving to another class, in order to avoid crowded hallways (PACER Center, 2018).