Expert consensus on the diagnosis and treatment of tic disorders in children
Tic disorders are multifaceted and common. It often causes confusion among clinicians and patients because the etiology as well as the pathogenesis are not clear. Many parents often fall for the so-called cure they are seeking. This article is published in the Chinese Journal of Pediatrics and is cited in sections with appropriate explanations for reference.
One of the clinical features
Concept
Tic disorders (TD) are neuropsychiatric disorders that begin in childhood and have tics as the main clinical manifestation. Its pathogenesis is the result of the interaction of genetic, biological, psychological and environmental factors, and the exact etiology and pathogenesis are unclear, with central neurotransmitter imbalance, striatal dopamine overactivity or postsynaptic dopamine receptor hypersensitivity as the key links in its pathogenesis. the incidence of TD has been increasing in recent years, and its clinical manifestations are diverse and its co-morbidities are complex, so the diagnosis and treatment need to be standardized.
I. Clinical features
1. General characteristics: The age of onset is 2 to 21 years old, with 5 to 10 years old being the most common. The disease is usually most severe at the age of 10-12 years; males are significantly more than females, and the ratio of males to females is 3-5:1.
2, twitching: an involuntary, purposeless, rapid, stereotyped muscle contraction. The performance of twitching is complex and diverse, classified in Table 1∞o. Among them, motor twitching refers to the involuntary, sudden, rapid contraction movement of the muscles of the head, face, neck and shoulders, trunk and limbs; vocal twitching is actually the contraction of the mouth, nose, throat and respiratory muscles, which vocalize through the airflow of the nose, mouth and throat. Motor tics or vocal tics can be further divided into two categories: simple and complex, and sometimes the two are not easily distinguished. Unlike other movement disorders, twitching occurs in the presence of normal motor function and is non-persistent. At the beginning of the disease, twitching symptoms usually start in the face and progress to the head, neck, and shoulder muscles, and then spread to the trunk and upper and lower extremities. The twitching may change from one form to another, with new forms of twitching constantly emerging. The frequency and intensity of the twitches fluctuate significantly during the course of the disease, and new twitching symptoms may replace or superimpose on top of the old ones. In children with a long course of the disease, the clinical picture is further complicated by the appearance of twitching or vocalization followed by a rapid attempt to disguise it. Twitching symptoms often come and go, and may resolve temporarily or spontaneously over time, or may be exacerbated or reduced by certain triggers. Common factors that aggravate tics include stress, anxiety, anger, shock, excitement, fatigue, infection, and being reminded of the tics. Forty to 55% of children with motor or vocal twitches are preceded by local discomfort, called sensory twitching, which is considered a precursor symptom (prodromal symptom), especially in older children. Motor or vocal twitches are likely to be associated with relief of local discomfort.
3. Co-morbidity: Approximately half of the children have one or more co-morbid psychobehavioral disorders¨1, including attention deficit hyperactivity disorder (ADHD), learning difficulties, obsessive-compulsive disorder, sleep disorders, mood disorders, self-injurious behavior, conduct disorder, and rage attacks. Co-morbidities of ADHD are the most common, followed by OCD. gender differences in the occurrence of TD co-morbidities exist, with ADHD, learning difficulties, conduct disorders and rage attacks usually occurring more frequently in males, while OCD and self-injurious behaviors occur more frequently in females than in males. Co-morbidities further increase the complexity and severity of the disorder.
This affects the healthy development of learning, social adjustment, personality and psychological quality of the child, and adds to the treatment and management of the disorder.
Expert consensus on the diagnosis and treatment of tic disorders in children in China, Part II Diagnosis
Diagnosis of tic disorders (TD)
1. Diagnostic methods: There is a lack of specific diagnostic indicators. At present, the diagnosis is mainly made by clinical descriptive diagnostic methods, based on the tic symptoms and related accompanying psychiatric behavioral manifestations of the child. Therefore, a detailed medical history is a prerequisite for a correct diagnosis, while physical examination including psychiatric examination and necessary auxiliary examinations are also necessary, and the purpose of the examination is mainly to exclude other diseases. EEG, neuroimaging and laboratory tests are generally not characteristically abnormal. A few
A few children may have nonspecific changes, such as background slowing or asymmetry in a few children on EEG, and nonspecific structural changes such as small volume of the caudate nucleus, slightly thin frontal and occipital cortices, mild enlargement of the ventricles, and deepening of the lateral fissure in a few children on cranial cT or MRI. Wilson’s disease) and other organic extrapyramidal diseases.
2, clinical typing: according to the clinical characteristics and duration of the disease, the disease can be divided into three types: transient TD, chronic TD and Tourette syndrome (TS). Transient TD is the most common type with the mildest disease, manifesting as one or more motor tics and/or vocal tics, and the duration of the disease is within 1 year. Chronic TD is the most common type of TD, with one or more motor tics and/or vocal tics, and lasts for more than one year. r11S, also known as multiple tics, is the more severe type, with both motor tics and vocal tics, but not necessarily both, and lasts for more than one year. In the past, the term “Tourette’s syndrome” was not appropriate, because the incidence of obscenities was less than one-third, and obscenities were not a necessary condition for the diagnosis of Ts, and it had an obvious pejorative meaning. Transient TD can be converted to chronic TD, and chronic TD can be converted to Ts. Some patients cannot be classified in any of these categories and belong to other types of TD that have not yet been defined, such as TD with adult onset (late-onset TD). Refractory TD is a new concept gradually developed in pediatric neurology and psychiatry clinics in recent years, which refers to children with TD who have not been treated for more than 1 year with adequate amounts of conventional anti-TD drugs such as haloperidol and thiopride, and whose disease course is prolonged. A variety of organic diseases can also cause TD, i.e. secondary TD, which should be excluded clinically. There are many causes of secondary TD, including genetic factors (e.g. Down syndrome, fragile X syndrome).
There are many causes of secondary TD, including genetic factors (such as Down syndrome, fragile X syndrome, tuberous sclerosis, neuroborreliosis, etc.), infectious factors (such as streptococcal infection, encephalitis, neurosyphilis, Creutzfeldt-Jakob disease, etc.), toxic factors (such as carbon monoxide, mercury, bee poisoning, etc.), drug factors (such as methylphenidate, pemoline, amphetamine, cocaine, carbamazepine, phenobarbital, phenytoin, lamotrigine, etc.) and other factors (such as stroke, head injury, developmental disorders, neurodegeneration, etc.). trauma, developmental disorders, neurodegenerative diseases, etc.).
3. Assessment of the disease: According to the severity of the disease, it can be classified as mild, moderate and severe. Mild (mild) means that the twitching symptoms are mild and do not affect the child’s life, learning or social activities; moderate means that the twitching symptoms are severe but have less impact on the child’s life, learning or social activities; severe (serious) means that the twitching symptoms are severe and significantly affect the child’s life, learning or social activities.
The severity of tics can also be measured according to the severity of tics. Objective and quantitative assessments can also be made based on tic severity scales, such as the Yale Comprehensive Tic Severity Scale¨ publication. In addition, the more co-morbidities associated with TD, the more serious the condition is.
4. Diagnostic criteria for tic disorders (TD).
It can be based on the International Classification of Diseases, 10th edition (ICD I10) 014], the Diagnostic and Statistical Manual of Mental Disorders, 4th revision (DSM-IV-TR) H. and the Chinese Mental Disorders and Diagnostic Criteria, 3rd edition (CCMD.III), and currently most scholars at home and abroad tend to adopt the DSM I 1V-TR in the diagnostic criteria, briefly described as follows.
(1) Transient tic disorders (tic disorders, TD).
①One or more motor twitches and/or vocal twitches;
(2) Multiple episodes of twitching in 1 d, with almost daily episodes lasting at least 4 weeks but not more than 1 year;
(iii) No previous history of chronic TD or Ts;
④Onset before 18 years of age;
⑤ TD symptoms were not directly caused by certain drugs (e.g., stimulants) or medical
(5) TD symptoms are not directly caused by certain drugs (e.g., stimulants) or medical conditions (e.g., Huntington’s chorea or post-viral encephalitis).
(2) Chronic tic disorders (TD).
(1) One or more motor or vocal twitches that do not occur simultaneously during the course of the disease;
②Twitches may occur several times a day, either daily or intermittently, but the interval lasts no more than 3 months, and the duration of the disease is more than 1 year;
③The onset of the disease was before 18 years of age;
TD symptoms are not caused by certain drugs (e.g., stimulants) or medical diseases (e.g., Huntington’s disease).
(4) TD symptoms are not caused by certain drugs (such as stimulants) or internal diseases (such as Huntington’s chorea or post-viral encephalitis).
(3) Tourette syndrome (TS).
(1) Multiple motor twitches and one or more vocal twitches during the course of the disease, which do not necessarily occur at the same time;
(2) The twitches may occur several times a day (usually in clusters) or intermittently, but the interval does not exceed 3 months.
The duration of twitching is more than 1 year;
③The location, number, frequency, intensity and complexity of the twitches vary with time;
④The onset of twitching before 18 years of age;
(5) Tic symptoms are not directly caused by certain drugs (e.g., stimulants) or medical conditions (e.g., Huntington’s chorea or viral infection).
Clinical diagnosis relies on a detailed history, physical examination and relevant ancillary tests. The child should be interviewed directly to observe the twitching and general behavioral manifestations, and to clarify the priority, scope, evolutionary pattern and sequence of symptoms. It should be noted that the symptoms of the child can be self-controlled for a short period of time and can be easily overlooked and missed. At the same time, TD is also easily misdiagnosed due to the frequent co-morbidity of ADHD and obsessive-compulsive disorder. It is important to exclude rheumatic chorea, hepatomegaly, epilepsy, pharmacogenic tics, psychogenic tics and other extrapyramidal disorders. The diagnostic process is shown in Fig.
The diagnosis of tic disorder in children is based on the diagnosis of post-infection encephalitis.
Domestic expert consensus on the diagnosis and treatment of tic disorders in children III Treatment
Treatment of tic disorders (TD)
Treatment principles
The target symptom for treatment should be determined before treatment, i.e. the symptom that has the greatest impact on the child’s daily life, learning or social activities. Tics are usually the target symptom of treatment, while some children have co-morbid symptoms, such as hyperactive impulsivity and obsessive-compulsive thoughts. The principle of treatment is to give equal emphasis to pharmacological and psychological-behavioral treatment, and to focus on individualization of treatment.
1.Pharmacological treatment: For children with moderate to severe TD that affects daily life, learning or social activities, if the effect of pure psychological-behavioral treatment is not good, additional pharmacological treatment is needed, including dopamine receptor blockers, only receptor agonists and other drugs. Medication should have a certain course and appropriate dose, and should not be changed or stopped prematurely.
(1) Commonly used drugs: commonly used drugs for the treatment of TD. Off-label drugs in the table include drugs used beyond the scope of disease indications and drugs used beyond the scope of age indications, and effective communication with parents of children should be conducted before using drugs and attention should be paid to monitoring the adverse reactions of drugs. Commonly used drugs mainly include the following four categories.
①Dopamine receptor blockers: they are the classic drugs for TD treatment. Commonly used drugs are as follows.
Haloperidol is commonly used in therapeutic doses of 1-4 m/d, 2-3 times/d, usually with an equal dose of benzhexol (Antan) to prevent possible pharmacogenic extrapyramidal reactions caused by haloperidol;
Thiopride, also known as Tebri, is commonly used in therapeutic doses of 150-500 mg/a, 2-3 times/d, with few and mild side effects, including dizziness, malaise, drowsiness, and gastrointestinal reactions; sulpiride is commonly used in therapeutic doses of 200-400 mg/d, 2-3 times/d, with sedation and mild extrapyramidal reactions more common;
Risperidone is commonly used in doses of 1 to 3 mg/d, 2-3 times/d, with common side effects such as insomnia, anxiety, irritability, headache, and weight gain; aripiprazole has been used in the treatment of children with TD with good efficacy” 7-is], with a recommended therapeutic dose of 5 to 20 mg/d, l-2 times/d, with common side effects such as nausea, vomiting, headache, insomnia, drowsiness, irritability and anxiety.
There are many other drugs in this category, such as perphenazine, olanzapine, quetiapine, ziprasidone, sertindole, piquantone, butylquinolizine, fluphenazine and trifluoperazine, all of which have certain anti-twitch effects and are not much used in pediatric clinics.
② Central a-receptor agonists.
Commonly used colistin system a2 receptor agonist, especially for children with co-morbid ADHD TD; commonly used therapeutic dose of 0.1-0.3 mg/d, 2-3 times/d; poor tolerance to oral preparations, can be treated with colistin patch; the drug has fewer side effects, some children appear sedation, a few children appear dizziness, headache, weakness, dry mouth, irritable, and Occasionally, postural hypotension and prolonged P-R interval are seen.
Guanfacine is also a first-line drug used for TD+ADHD treatment, and there is little experience in domestic pediatrics.
③ selective 5hydroxytryptamine reuptake inhibitors: new antidepressants, such as fluoxetine, paroxetine, sertraline, fluvoxamine, etc., have anti-twitch effects; combined with risperidone can produce synergistic effects; can also be used for TD + obsessive-compulsive disorder treatment.
Clonazepam, sodium valproate, topiramate and other drugs have anti-TD effects, of which clonazepam treatment dose is 1-2 mg/d, 2-3 times/d, common side effects are drowsiness, dizziness, weakness, vertigo, etc.; sodium valproate treatment dose is 15-30 mg/(kg・d), pay attention to side effects such as liver function impairment; topiramate treatment dose is 1-4 me/(kg・d ), side effects such as loss of appetite, weight loss, sweating disorder and cognitive impairment should be noted. Children with refractory TD should be promptly referred to psychiatry or functional neurosurgery for further pharmacological or neuromodulatory treatment. The application of multi-receptor modulating drugs in combination or the exploration of new drugs has become the trend in the treatment of refractory TD.
(tic disorders, TD drug treatment options.
① Preferred drugs: thiopride, permethrin, sulpiride, aripiprazole, colistin, guanfacine, etc. can be used. Start from the lowest dose, and gradually increase the dose slowly (once every I-2 weeks) to the target therapeutic dose.
②Intensive treatment: After the disease is basically controlled, the treatment dose needs to be continued for at least I~3 months and intensive treatment is given.
The purpose of intensive and maintenance therapy is to consolidate the therapeutic effect and reduce relapse.
④Discontinuation: After the maintenance treatment phase, if the disease is completely controlled, the drug can be considered to be gradually reduced and discontinued, and the reduction period is at least l to 3 months. If the symptoms recur or worsen, resume the medication or increase the dose.
⑤ Combination medication: When the use of a single drug can only partially improve the symptoms, or when there are co-morbidities, a neurological consultation can be considered to consider combination medication; refractory TD also requires combination medication.