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CHAPTER 37 • Mental Disorders of Childhood and Adolescence

TIC DISORDERS AND TOURETTE SYNDROME

syndrome to have a comorbid mental, behavioral, or developmental disorder. More than a third of individuals with Tourette syndrome have OCD. Other comorbid diagnoses include anxiety (61%), ADHD (52%), behav ioral issues (34%), learning disabilities (34%), develop mental delays (26%), autism spectrum disorder (21%), and depression (20%). In addition, over 40% of children with Tourette syndrome have a co-occurring chronic health condition (CDC, 2024d). The precise nature of the underlying pathophysiology in this primarily inherited disorder is unclear, but the basal ganglia and functionally related cortical areas are pre sumed to play a central role. Findings from neuroimaging studies are consistent with the presumption that a dysreg ulation of the corticostriatal–thalamic circuitry of the brain underlies Tourette syndrome. In addition, multiple genes on different chromosomes interacting with environmental factors are involved. Several neurotransmitters (dopamine, serotonin, and norepinephrine) have been implicated in the etiology of Tourette syndrome (NIH NINDS, 2024). Family Response to Disorder Before evaluation and diagnosis of Tourette disorder, most families struggle with various explanations for the child’s tics. Because tics fluctuate in severity with time and may be more prominent in some settings than in oth ers, family members may have difficulty understanding their involuntary nature. Some parents may be convinced that the tics are deliberate and done to secure attention; others may judge that the tics are “nervous habits” indic ative of underlying trouble. Such views require recon ciliation with the currently accepted view that tics are involuntary. Some parents may conclude that the child is incapable of controlling any behavior because of Tourette disorder. They may subsequently feel uncertain about setting limits. In these families, delineating the boundar ies of Tourette syndrome can be helpful (CDC, 2024d). On learning that this disorder is probably genetic, some parents may harbor guilt for having passed it on to their child. The nurse can assist such families by listening to these concerns and providing information about the natural history of Tourette disorder—it is not a progres sive condition, tics often diminish in adulthood, and it need not restrict what the child can achieve in life.

Tics are sudden twitches, movements, or sounds that indi viduals do repeatedly without their control. Tics can be transient or chronic. Motor tics are generally quick jerky movements of the eyes, face, neck, and shoulders, although they may involve other muscle groups as well. Occasionally, tics involve slower, more purposeful, or dystonic move ments. Vocal tics typically include repetitive throat clear ing, grunting, or other noises but may also include more complex sounds, such as words; parts of words; and in a small percentage of patients, obscenities. Transient tics by definition do not endure over time and appear to be fairly common in school-aged children. Tic disorder is a general term encompassing several syndromes that are chiefly char acterized by motor tics, vocal tics, or both. KEYCONCEPT Tics are sudden, rapid, repetitive, stereotyped motor movements or vocalizations. TOURETTE SYNDROME Tourette syndrome , the most severe tic disorder, is defined by multiple motor and vocal tics for at least 1 year. Because no diagnostic tests are used to confirm this disorder, the diagnosis is based on the type and duration of tics present. Early symptoms of Tourette syndrome (gen erally in the head and neck area) typically occur in early childhood, with an average onset between the ages of 5 and 10 years. Most individuals with Tourette syndrome experience their most severe tics in their early teens, with tics typically lessening and becoming more controllable by late teens to early 20s (National Institute of Health, National Institute of Neurologic Disorders and Stroke [NIH NINDS], 2024). Motor tics generally precede vocal tics, and parents often describe the seeming replacement of one tic with another. In addition to this changing reper toire of motor and vocal tics, Tourette syndrome exhibits a waxing and waning course. The child can suppress the tics for brief periods. Thus, it is common to hear from parents that their child has more frequent tics at home than at school. Older children and adults may describe an urge or Studies estimate that 1 out of every 162 children (0.6%) has Tourette syndrome, of which only half are diagnosed. Among those diagnosed, 44% report moderate to severe symptoms. Symptoms generally occur for around 2 years before receiving a formal diagnosis. Male children are three times more likely to have Tourette syndrome than female children, and rates are similar among children from all racial and ethnic groups or socioeconomic back grounds. Over 80% of children diagnosed with Tourette a physical sensation before having a tic. Epidemiology and Etiology

EVIDENCE-BASED NURSING CARE FOR CHILDREN WITH TOURETTE SYNDROME Recognizing Cues: Relevant Assessment Information

Nursing assessment of a child with tics includes a review of the onset, course, and current level of the symptoms. Goals of the assessment are to identify the frequency,

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