What Are the Early Warning Signs of Tics in Children?

What you need to know

• Certain behavioral and emotional symptoms may appear before the onset of tics in children at high risk for developing tic disorders.
• Early warning signs differ between boys and girls - boys tend to show conduct problems and autism-like traits, while girls more often have compulsions and emotional issues.
• Monitoring high-risk children from preschool age, with attention to sex differences, may aid in earlier detection and treatment of tic disorders.

Background on tic disorders

Tic disorders, including Tourette syndrome, are neurodevelopmental conditions that cause involuntary movements or vocalizations called tics. Tics typically first appear in childhood, usually between ages 3-8 years old. Tic disorders affect about 1% of children and are more common in boys than girls.

Many children with tic disorders also have other mental health conditions, especially attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). This can make tics more difficult to recognize and diagnose early on. On average, there is a delay of about 10 years between when tics first appear and when a child is formally diagnosed with a tic disorder.

Earlier detection of tics could allow for earlier treatment and support, potentially improving outcomes. However, it has been unclear whether there are early warning signs that might predict which high-risk children will go on to develop tics. This study aimed to identify clinical symptoms that may precede and predict the onset of tics in children with a family history of tic disorders.

How the study was conducted

The researchers followed 187 children between ages 3-10 who had a sibling or parent with a chronic tic disorder but did not have tics themselves at the start of the study. These children were considered at high risk for developing tics.

The children were assessed every 2 months for up to 7 years to check for the emergence of tics. Their parents also completed questionnaires at the beginning of the study about various behavioral and emotional symptoms the children were experiencing.

Out of the 187 children, 61 went on to develop tics during the study period. The researchers compared the baseline symptoms of these 61 children to the 126 children who did not develop tics, to see if there were any early differences that predicted who would develop tics.

Key findings on early warning signs

The study found several clinical symptoms present at baseline that were associated with later development of tics:

• Being male
• Younger age
• More severe conduct problems (aggressive or rule-breaking behaviors)
• More autism spectrum traits (social difficulties, restricted interests)
• More compulsive behaviors
• More emotional problems (anxiety, depression)

Interestingly, the early warning signs differed between boys and girls:

For boys, the strongest predictors of later tic onset were:

• Conduct problems
• Autism spectrum traits

For girls, the strongest predictors were:

• Compulsive behaviors
• Emotional problems
• Oppositional defiant behaviors

Symptoms of ADHD and obsessions were not significant predictors of tic onset in this study.

What this means for identifying tics early

These findings suggest there may be subtle behavioral and emotional differences in children even before tics emerge that could signal increased risk. However, these early signs look different in boys versus girls.

For boys, disruptive behaviors and social difficulties may be key early indicators to watch for. For girls, repetitive behaviors, anxiety/depression, and oppositional behaviors appear to be more relevant warning signs.

Monitoring these symptoms in children with a family history of tics, starting from preschool age, could potentially help identify those at highest risk. This may allow for earlier detection once tics do start to appear.

The sex differences highlight the importance of considering boys and girls separately when assessing tic risk. Girls’ warning signs may be less obvious externally, which could contribute to delayed diagnosis.

Persistence of tics after onset

An additional finding was that in most children who developed tics, the tics persisted for at least a year after onset. Specifically:

• 66% had chronic tics lasting at least 12 months
• 32% had tics lasting between 4 weeks and 12 months
• Only 2% had tics that resolved within 4 weeks

This challenges the common belief that childhood tics are usually temporary. It suggests that in high-risk children, tics that emerge are likely to persist and may warrant ongoing monitoring and support.

Limitations and next steps

Some limitations of this study include:

• The sample only included children with a family history of tics, so findings may not apply to the general population.
• Symptoms were only assessed at the start of the study, not continuously over time.
• The average age of tic onset was slightly older than in some previous studies.

Future research could:

• Include younger children to capture even earlier potential warning signs
• Assess symptoms at multiple time points leading up to tic onset
• Compare high-risk children to those without a family history of tics
• Explore genetic and environmental factors that may influence early symptoms and tic development

Conclusions

• Certain behavioral and emotional symptoms may precede and predict the onset of tics in high-risk children.
• Early warning signs differ between boys and girls, highlighting the need for sex-specific monitoring.
• Regular assessment of high-risk children from preschool age may aid in earlier detection and treatment of tic disorders.
• Tics that emerge in high-risk children are likely to persist for at least a year in most cases.