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Tics, Twitches and Tourette's: When to Worry and What to Do · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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  I'm Holly Wehmins, and this is Pediatrics Now, cases, updates,
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  and discussions for the busy pediatric practitioner.
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  Click on the link in this podcast for free credit that includes CME,
• 0:12
  MOC, or ethics credit, depending on our topic or podcast.
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  I'm so excited today because joining us here in the podcast studio is Dr.
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  Sheldon Gross, who has been practicing neurology for 42 years now. That's correct.
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  Dr. Gross, thank you so much for being here in the podcast studio.
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  I've been looking forward to this, Holly.
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  And off the top, I want to mention also thank you for curing my migraine headaches.
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  I had migraine headaches for more than 20 years, and you gave me some great
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  advice, and it was about the headache diet, and it really works.
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  I mean, it was incredible.
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  I'm delighted, and I wish I met you 20 years ago.
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  Thank you so much. And we do have a podcast episode in our news feed about the
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  headache diet in case you're interested and want to talk to your patients about this.
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  And we have a version on our Pediatrics Now for Parents podcast,
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  the sister podcast. So we have that episode as well.
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  So today we're talking about ticks and twitches.
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  Dr. Gross, for our listeners, can you start by explaining the difference between a tick and a twitch?
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  Community pediatricians see this a lot.
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  Holly, when people say tics, what they're referring to is what I would call
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  a nervous mannerism, just a nervous habit that people have.
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  Probably the most common one is eye blinking. You may have friends that just
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  have this habit of nervously blinking their eyes.
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  It can be either movement, it can be making noises or making sounds.
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  It can take a hundred different forms.
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  And in terms of twits, that's a much more nonspecific term.
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  A twits could be one of 20 different things.
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  A tick is something that's very specific for one particular condition,
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  which we're going to talk about today.
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  Yes, so let's dive in. So when parents describe eye blinking or throat clearing,
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  what helps you decide whether it's a motor tick versus something else?
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  Well, a motor tick is something that kids will do over and over again.
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  When you ask them, why are you doing that? They typically say either,
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  I don't know, or they will say, I just have this urge to do this, and I can't control it.
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  They're awake during this. They're alert during this.
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  Sometimes they know they're doing it. Sometimes they don't know they're doing
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  it. There's one thing I've learned to do, which is amazingly simple.
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  I'll ask people to repeat and show me what it is that they do.
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  And for patients with tics, they can say, oh, I do this. And then they'll show
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  you the way they posture their hand or wiggle their nose or whatever.
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  And for other conditions, she can't do that. A tick is totally harmless.
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  And I've seen so many families that come in really anxious about this,
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  really concerned that their child has some horrible condition.
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  And once I determine that these are ticks, the very first thing I do is tell
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  them their child is fine.
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  This is not a dangerous problem.
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  This doesn't cause any problem at all. In fact, what I see happen,
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  Holly, is I see a terrible cycle develop.
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  A child will be having tics. The family is incredibly anxious.
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  The child picks up on the anxiety, and that makes the child anxious,
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  which in turn makes the tics worse.
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  So the first thing I have to do is break that cycle, convince people that this
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  is not a dangerous problem, that their child is healthy, and I really tell them
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  as much as possible just to try to ignore it. Don't comment on it at all.
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  I'll never forget one father that had a stopwatch and was timing his child to
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  see how many tics he had in one minute. Really?
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  And that's the absolute worst thing you could do. So there's a lot of things
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  that we can accomplish with very little effort.
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  And it's hard as a parent not to do that. I know with my daughter,
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  when she's having an ear infection and she's not hearing as well,
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  and I have to try to stop myself from asking her every hour,
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  like, are you hearing better now?
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  How is it going? And then that creates this anxiety.
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  You know what I tell the medical students? So I say, well, take patience.
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  Once I'm sure what I'm dealing with, I'll spend five minutes with the patient
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  and 45 minutes with the parents.
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  Because you really have to get at that anxiety in order to make any progress at all.
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  Do we know what causes tics? Well, we probably think that in many cases there's a genetic component.
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  I can tell you that there is a small Mennonite community in Alberta, Canada.
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  One of the founding fathers had Tourette's syndrome, and there was a lot of inbreeding.
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  So now 25% of the people there were a descendant of this one individual,
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  and 25% of that community has Tourette's syndrome. them.
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  So we know that in some instances there's a genetic component.
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  In other instances, we really don't know. What we do know is what makes it worse.
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  And so often that's the first thing I'll go through with families.
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  I don't go right to medicine. I'll say, let's talk about some of the things
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  in your child's life or environment that may be making this worse or maybe even
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  causing it in the first place. Video games?
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  Well, not necessarily video games, although maybe. I've written down a list of things.
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  Without any question, the most common thing that makes ticks worse is stress.
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  And that is much more common than just about anything else.
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  So once I've determined a child is having ticks, I'll say, what is your child's
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  life like? What's going on? Is he in a new school?
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  I've had patients that were bullied at school and developed ticks or worsening ticks.
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  Sometimes there's stress in the family. I've had kids where the parents are
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  going through a separation or a divorce.
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  That type of stress often aggravates tics or can even cause tics from the very start.
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  And then once I've gone through that, I start asking other questions.
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  Specifically, are there any other medicines that the patient is taking?
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  There's one medicine in particular that is famous for causing tics,
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  and those are the stimulants.
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  Medicines for ADHD such as Ritalin or Adderall or Vyvanse, you may have heard of all these. Yes.
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  They can be very effective for ADHD, but they can also make ticks much worse.
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  So if I have a patient who's got ADHD, and there's a very strong relationship
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  between these two, ticks and ADHD, the two occur very commonly in the same patient.
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  I do everything I can to avoid using stimulants.
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  And if they're already on a stimulant, I'll suggest let's get you off of a stimulant
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  and use a different type of a medicine.
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  And along with stimulants, caffeine fits right in there. So I'll tell kids,
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  try to limit or even eliminate how much caffeine you drink.
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  Other things that can do it, we know that a lack of rest or inefficient sleep
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  can result in tics or worsening tics.
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  And getting back to what I said initially, profound anxiety and depression can all do this.
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  So before I even mention medicine, I go through all these different aspects
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  because I think fewer than 50% of my patients with Tourette's syndrome go on medicine.
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  Just like I helped you with your migraine with diet, there's a lot you can do
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  to help patients with Tourette's syndrome and tics that does not require medicine.
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  And talking about the anxiety and depression, I know we're going to be talking
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  today about how psychiatry and neurology overlaps, and then that's clearly an
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  area where there's this overlap, and this,
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  as we all know, there's this epidemic right now of anxiety and depression.
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  Well, you're exactly correct, and I like to tell the students and interns that
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  come through and work with me.
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  I've had patients with Tourette's syndrome or tics, and we'll talk about Tourette's
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  syndrome in just a moment, that actually never come under control until we do
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  something about stress and anxiety and possible depression.
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  Perhaps that means working with a family therapist. Perhaps it means going on
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  medicine, not for tics, but for stress and anxiety.
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  And I try to convince all the students, you can attack a problem two different ways.
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  You can give medicine for the problem itself, in this case, tics,
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  or you can try to attack the underlying factors that are making the tics worse.
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  And that's what we were just talking about. And in fact, a lot of my patients
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  really respond beautifully to medicine for stress and anxiety,
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  and you don't have to give them medicine for tics.
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  So there's not evidence, as far as we know, though, showing our.
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  Increasing time spent in front of screens, that that's causing it,
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  it's probably not helping it?
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  Or do you want to say anything about that? I would say it depends on what you're watching.
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  I don't think the video by itself does anything. But if you're watching something
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  that results in increased stress or makes a child anxious or even depressed,
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  then yes, it can affect tics.
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  But if you're watching something otherwise, then I think it's very questionable
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  whether that matters or not.
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  I would imagine it's also difficult in school for kids if they're having a tick
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  and then their friends, classmates are then responding to the tick in some way.
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  That's not helping the anxiety.
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  And that varies immensely from one person to the next.
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  Let me take just a moment and talk about what Tourette's syndrome is.
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  Yes, when do we worry about Tourette's? First of all, Tourette's syndrome is
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  not a separate type of disease like cancer or diabetes.
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  Tics comes in this huge spectrum all the way from very, very mild to overwhelmingly severe.
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  And a group of individuals got together and said, let's take this subset of
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  tic patients and let's call this Tourette syndrome or initially Gilles de la Tourette syndrome.
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  Now people just call it Tourette syndrome. And it's really three different things
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  that you have to satisfy.
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  You have to have the presence of motor tics, which is movement,
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  whether that's eye blinking or wiggling your nose or making some type of arm
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  and shoulder and neck shrug or something of that nature.
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  You also have to have vocal tics, which means not necessarily saying words,
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  but making noises, snorting, coughing.
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  Any kind of a noise is considered a vocal tic.
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  And the last requirement is it has to be there for at least a year.
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  So if you have the patient who has motor tics, vocal tics for longer than a
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  year, you would say it's Tourette's syndrome.
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  But I have to spend time with the family to explain, I'm not telling you anything
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  that you don't already know.
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  You already know that this has been here longer than a year.
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  You already know that it involves both movement as well as speech.
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  Some people think Tourette's is a separate disease or a separate entity, and I try to dispel that.
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  That's the first thing. Now, in terms of what you do, that depends entirely
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  on how the child is affected.
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  I can tell you that many times I have families come in horribly upset, horribly anxious.
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  And then I'll look at the kid and I'll say, do these bother you?
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  And they'll say, no, they don't bother me at all.
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  I do this, but I don't care. No one really bugs me. I'm a happy guy.
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  So what do you do in that case? You again, spend 45 minutes with the family
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  trying to convince them they have a healthy child, leave him alone.
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  I try to say in the nicest way possible, go away and don't come back.
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  In other words, we don't need to do anything right now.
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  So when, and also when you say we don't need to do anything right now,
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  but what if they don't go away in a year?
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  It eventually boils down to how is the child affected by this?
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  Are these ticks intrusive in his life.
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  And usually, this is going to sound very unscientific, but what I do is I basically
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  look at the child and say, would you like to take medicine for this?
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  And if he says yes, then I talk about medicine.
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  But I try to not do it unless I'm sure it's making a difference because so many
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  people have tics and it just doesn't bother them at all.
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  But if a child says, I'm feeling very self-conscious, I'm feeling isolated,
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  my friends are teasing me or anything like that.
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  And if he says, yes, I want to take medicine, that's when we talk about the option of medicine.
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  So is what you're saying, Sheldon, is it a form of Tourette's,
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  but a very mild form if a child has for a short time even a tick?
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  Or is that way off? It has to be at least a year.
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  Okay, otherwise it's not. It's just you would call it a tick disorder.
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  You would not use the term Tourette's syndrome. Okay.
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  And even before medicine, there's other things I'll try first.
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  There's a program here at UT Health in San Antonio where they try to train children
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  how to control ticks on their own without the use of medicine.
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  Or if it's a very disturbing, distracting tick, like making a loud whooping
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  noise or something, which in a classroom, teachers can get upset about that.
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  They try to teach them how to substitute something else like wiggling their
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  finger underneath the desk or something that is not disruptive.
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  So typically in most instances, if it's an option, I'll try to get them to go
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  to this program first to see if they can find a non-medical way of helping a child control ticks.
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  Is part of that because there's so much sitting involved in school all day? Well, possibly.
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  Possibly. And a lot of it could be from a thousand different factors.
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  It could be a child with learning disabilities who's concerned he's going to
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  fail three different classes.
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  It can be someone who's moved from another town and he's trying to make friends
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  and having a tough time of it.
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  It could be someone who's bullied. I mean, there's really an endless list of
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  things in school that might trigger ticks.
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  So when should a pediatrician refer to neurology if their patient is coming in with a tick?
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  Well, if the patient says, and if the family says, our son is miserable and wants to take medicine,
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  and if the pediatrician is not comfortable himself, that's when he should refer
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  either to a neurologist or sometimes child psychiatrists take care of this as well.
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  But a lot of pediatricians will treat this themselves if they're comfortable with the medicine.
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  Yes. So can you talk about that a bit? What can be treated in the office?
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  What would your advice be?
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  Well, if we've done all those other things, if we've determined this is a child
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  where the tics really aren't and the Tourette's is really having a negative effect on him.
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  If you've tried this program I told you about that it's not working,
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  and if he and the family are both saying we want to take medicine for this,
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  then you can start with very simple things that I think a lot of pediatricians are already using.
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  There is a medicine called guanfacine, which is commonly used to treat attention deficit disorder.
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  Guanfacine is also, in many instances, very effective at suppressing ticks.
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  There's another medicine, clonidine, which is similar to guanfacine.
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  It also suppresses ticks.
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  And there are other medicines, what we call the dopamine blockers,
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  medicines like Abilify, Risperdal.
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  Those medicines can be effective. And then there's another medicine that's actually
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  a seizure in a migraine medicine called Topamax or Topiramate,
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  where there's more and more interest in using that to suppress tics as well.
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  And since we're talking about treatment.
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  I also try to tell the medical students, whenever you're starting a treatment
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  plan, talk about your goals right off the bat so the family knows what it is
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  you're trying to accomplish.
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  For patients with Tourette's, you rarely get them completely free of tics.
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  That typically does not happen, and that's not really my goal.
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  My goal is to get to where the tics are not intrusive in his life,
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  to get to where the tics are no longer a real problem for him.
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  Is it the same medications you're mentioning for tics and tics caused by Tourette's?
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  Yes, you would use the same types of medicines. And that program I told you
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  about, we call it CBIT, the Cognitive Behavioral Intervention Therapy.
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  That program works for patients that have full-blown Tourette's as well as people
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  that have just a plain simple tic disorder.
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  And so for our listeners in the San Antonio area, can you tell us more about where that is?
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  It's here in San Antonio. I would have to look at my telephone to get the phone number.
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  Well, we could put a link into it. And it's referred to as the Tourette's Syndrome Program.
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  How common are transient tics in children, and how often do they resolve on
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  their own versus progress to a chronic condition?
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  They're very common. In fact, of all the types of movement disorders that we
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  see in child neurology, without any question, tics are the most common type of movement disorder.
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  And whoever sent in that question, that's a very good one, because many times
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  ticks do resolve, especially if they're related to some severe stress or anxiety,
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  and you're able to somehow fix whatever it is that's the root of that.
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  Or if they're on a medicine like Ritalin, and you take them off,
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  a lot of the times they'll go away,
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  and sometimes they'll just go away spontaneously, and you don't know why.
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  But the answer is yes, they do often go away by themselves.
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  Sheldon, is there an age window when you most often see transient tics?
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  I tend to see tics probably, initially, probably, I would take a guess between
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  age five all the way through adolescence.
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  They can start really any time at all.
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  And probably there have been cases where it's younger than age five.
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  So it's a very wide range. And I don't think there's any specific hard and fast
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  rule for how old you have to be before you have tics.
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  So Sheldon, there's often an overlap between neurology and psychiatry when it comes to tics.
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  How do you approach distinguishing between neurological and psychiatric causes in your practice?
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  That is such a great question, and that leads into the second part of our conversation today.
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  I'm trying to start a new clinic here at UT. I'm trying to start a clinic where
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  we use the term dual diagnosis, which means you have a neurological diagnosis
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  plus a psychiatric diagnosis.
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  Because I have so many patients that have migraine and depression,
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  or they have seizures and bipolar syndrome, or they have something else with
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  a horribly chaotic, anxiety-provoking family situation.
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  And sometimes it's very difficult to separate what is psychiatric and what is neurological.
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  Those two so rapidly or so frequently are all mixed in together.
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  And if you have any question, you have to either refer to either a family therapist
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  or if you think someone needs to be placed on medicine, you try to get a psychiatrist involved.
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  But let me switch over now for just a second, because I like to tell people
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  that all sorts of talks start out with some type of seed.
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  Something plants an idea in your head or an experience that.
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  Affects you and makes you want to give a talk about something.
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  Before I give this talk about overlap between neurology and psychiatry,
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  I've had two experiences that affected me.
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  One experience was a call from an ER doctor almost apologetically saying,
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  I've got this teenage girl here with classic panic attacks, and the family's
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  insisting on going to see a neurologist.
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  I feel like I'm wasting your time, but would you be willing to see this patient?
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  So I said, fine. And she came and I heard about her symptoms and it sounded
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  like classic panic attacks.
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  But because they went to the trouble to come and see me, I did the EEG.
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  And lo and behold, she had seizure discharges coming from her left temporal lobe.
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  So what people had been describing as panic attacks were, in fact,
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  a form of temporal lobe seizure.
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  Wow. I put her on seizure medicine, and that was the last episode she ever had.
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  I never forgot that. That's amazing. And then my second seed that got me interested
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  in this was when I was asked to see a patient, a teenage boy,
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  who arrived in the emergency room floridly psychotic,
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  hallucinating, agitated, not making any sense, with no history whatsoever of
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  previous psychiatric illnesses.
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  And I gave him medicine the next day he was back to normal. So as I was talking
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  to him, I said, what's the last thing you remember?
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  He said, well, I remember having a severe headache and seeing purple spots in my vision.
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  This was a migraine patient. And as I've delved into this in greater detail,
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  there is something called migraine psychosis.
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  A migraine can either cause confusional episodes where you may be disoriented
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  and you may not know where you are or make sense, and that can escalate into full-blown psychosis.
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  So what appeared to be acute psychosis was, in fact, a migraine disorder.
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  And I gave him—we spoke about the same dietary things, and I gave him medicine.
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  He never had another episode again.
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  Those two experiences really had an effect on me. It made me realize how a neurological
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  condition can really present with psychiatric symptoms.
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  What are the red flags when a family comes in for their child having what could
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  be tics or twitches, but it really could be a seizure?
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  Let me first of all say I've had several patients that were referred to me for
• 22:01
  tics and in fact did end up with seizures.
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  First of all, if someone comes in with multiple different habits,
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  wiggling their nose, making noises, blinking their eyes, that's not the type
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  of patient you have to worry about. That's fairly definite tics and probable Tourette syndrome.
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  And again, I'll just tell you about patients I've seen.
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  A tic can involve unusual rolling of the eyes or different eye movements.
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  That's when I'll pull out the question, show me what it looks like,
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  and if they just do the exact same thing, that's much more suggestive of a tic.
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  I had one patient I almost sent out of my office with a diagnosis of tics.
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  He had unusual eye movements, but they always went to one side.
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  And I sit there and watched him. The eye movements looked like them IP ticks,
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  but he only went to the left. They never went to the right.
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  And I thought I was going to waste their money, so I said, let me do an EEG.
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  And again, lo and behold, he had seizure discharges.
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  That patient ended up with a large cyst in his brain and had to have surgery.
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  And I almost sent him out of the office with the diagnosis of ticks.
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  I've had other patients where a tick can be a sudden jerk, a jerk of the shoulders, a jerk of the arms.
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  And there's a type of a seizure called a myoclonic seizure that can look just like that.
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  So what I would tell people is, if there's any question in your mind,
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  certainly if people say, yeah,
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  he'll do these and he's sleepy and tired afterwards, that's not a tick.
• 23:28
  If anyone has any of those symptoms after it's over, that's much more likely to be a seizure.
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  If it's something that they cannot easily reproduce for you,
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  that's much more likely to be a seizure.
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  If there's any pre-existing history, if there's a family history of epilepsy,
• 23:45
  if the patient has had a serious traumatic brain injury or if he's had an infection
• 23:51
  like meningitis or encephalitis,
• 23:53
  if the patient has a genetic condition such as Down syndrome or other genetic
• 23:59
  conditions where we know or autism,
• 24:01
  autistic patients have a very high incidence of epilepsy.
• 24:05
  In all those instances, I would recommend they be referred to a neurologist
• 24:09
  and very likely have an EEG done.
• 24:12
  And we have a Grand Rounds talk by Dr. Mario Fierro on autism that was just
• 24:18
  released that's in our Pediatrics Now news feed.
• 24:21
  I heard it, and that was a superb presentation. He did such a great job.
• 24:27
  Sheldon, can anxiety or obsessive-compulsive behaviors mimic or exacerbate tics?
• 24:33
  I know you've mentioned this earlier in the interview, but what clues tell us
• 24:38
  it's stress-related versus a primary movement disorder?
• 24:42
  Sometimes there's no substitute for talking to people, Holly.
• 24:46
  You just have to talk to people. And you just have to explore and probe and
• 24:51
  dig, maybe get some feedback from teachers, talk to their parents.
• 24:56
  I'm not sure you can tell just by looking at people what is induced by stress.
• 25:00
  But you bring up a very interesting point, which is, what are some of the other
• 25:05
  conditions that can be associated with tics or associated with Tourette's syndrome?
• 25:11
  I've already said that ADHD is much more common in patients with tics than in
• 25:16
  the general population.
• 25:17
  But probably the second most common thing is obsessive-compulsive disorder.
• 25:22
  So rather than saying, is this, when people ask me, do I have Tourette's syndrome
• 25:27
  or do I have obsessive-compulsive disorder, the answer is yes.
• 25:32
  Because people have both. And when you think about it, what is the difference
• 25:36
  between someone having an urge to roll his eyes a certain way versus having
• 25:41
  an urge to take two steps forward and two steps backward?
• 25:44
  One we would call a tick, one we would call OCD. I think we're talking about
• 25:49
  different parts of the spectrum.
• 25:52
  So obsessive-compulsive disorder is very commonly seen in patients with Tourette's syndrome.
• 25:59
  And I would add other things commonly seen, depression, anxiety,
• 26:04
  bipolar syndrome, pretty much the whole list of things that can occur in child
• 26:09
  psychiatry occur more frequently in patients with Tourette's syndrome.
• 26:14
  This is all so insightful.
• 26:17
  Dr. Sheldon Gross with Pediatric Neurology here at UT Health and University
• 26:22
  Hospital, thank you so much for being here today on Pediatrics Now.
• 26:26
  This has been wonderful.
• 26:28
  Well, let me put in one more plug. Sure. There's six of us. I'm the weakest link.
• 26:34
  You're humbled. The other five are younger than I am, incredibly bright,
• 26:40
  very interested in getting involved in our community.
• 26:43
  Some have already been here for 10 or 15 years. some are brand new right out
• 26:47
  of their training program.
• 26:49
  Part of why I love this job so much is the other five child neurologists are
• 26:53
  wonderful people and superb clinicians.
• 26:56
  I'm very happy to be associated with this type of group. And I know you'd love
• 27:00
  seeing patients and you're also very humble and highly experienced and knowledgeable.
• 27:06
  Dr. Sheldon Gross, don't forget to click on the link in this podcast for free
• 27:10
  credit that may include CME, MOC, or ethics credit.
• 27:15
  Pediatrics Now is brought to you by the Department of Pediatrics at UT Health San Antonio and.