Voice tics in children. Nervous tics in children

Vocal tics in children are the involuntary pronunciation of various sounds, simple or complex in nature. Tics can be provoked by respiratory infections, after illness with bronchitis, tonsillitis, rhinitis. Mental overload, head trauma are additional external factors leading to the appearance of tics. It is important to rule out the possibility concomitant diseases by contacting a psychotherapist and a neurologist for an accurate diagnosis.

The main causes of vocal tics in children are purely psychogenetic in nature:

• Heredity - the disease is more likely to occur in children whose parents are also prone to tics or "neuroses obsessive states". Symptoms may appear more early age than the parents.
• Restless environment (at home, at school, kindergarten) - conflicting parents, overwhelming demands, prohibitions, or complete absence control, lack of attention, mechanical attitude: wash, feed, sleep.
• Severe stress - the trigger for a tic can be fright, emotional trauma associated with abuse, news of the death of a relative.

Also, tics can have physiological causes, for example, serious illness, lack of magnesium in the body, disruption of the central nervous system as a result of:

• circulatory disorders of the brain;
• head injury;
• transferred meningitis;
• intracranial hypertension.

If children suffer from depression, then the risk of their tics is high.

Symptoms

Simple vocal tics include grunting, coughing, whistling, noisy breathing, grunting. The child makes lingering sounds “ay”, “ee”, “u-u”. Other sounds such as screeching or whistling are somewhat less common.

Symptoms manifest themselves singly, serially, are status. If the day has been emotional, the patient is overworked, and the symptoms are worse in the evening. Simple tics in ¼ of patients are manifested with motor tics in low and high tones:

• At low - the patient coughs, clears his throat, grunts, sniffs.
• At high - the sounds are already more definite, some vowels. High tones are combined with shudders.

Also, children are diagnosed with complex vocal tics whose symptoms are:

• pronunciation of words, including abusive ones - coprolalia;
• constant repetition of the word -;
• fast, uneven, illegible speech - palilalia;
• repetition of words, mumbling - Tourette's syndrome (watch the video).

Such manifestations cause a lot of problems, because children cannot attend school normally due to outbursts of an uncontrolled flow of abuse and other speech disorders.

Treatment

The treatment of vocal tics in a child is carried out on an outpatient basis so that hospitalization does not increase the anxiety that will aggravate the disease. The child must be observed pediatric neurologist. In 40% of children, tics disappear on their own, the rest have to be treated for a long time and painstakingly. Very effectively conducts conversations with a psychologist, which organizes therapy for the child and his parents. Understanding by parents the insurmountable nature of the disease will only hasten recovery.

Attempts to suppress tics by willpower usually result in aggravation anxiety state in a child, causing a new, even more pronounced wave of symptoms. Therefore, to pull back, to remind him to restrain himself, and even more so to punish him, is cruel and unacceptable.

If the child's tics are caused by psychological reasons, it will be enough to normalize the family environment, create a friendly, favorable atmosphere which will provide the most effective treatment.

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Remove excessive emotional stimuli from the child's environment. It doesn't matter if they are positive or negative - it's stress. Even an attempt to divert the child's attention from the problem by coaxing gifts, travel is a serious burden on the central nervous system. It is better to organize a sparing day regimen, a calm atmosphere in the house.

• Take note:

Analyze what is the "trigger" that provokes vocal tics in your child. Finding out the source of irritation, eliminate it.

Often the source is watching TV, especially if the lights are off. The flickering light on the TV screen changes the bioelectrical activity of the child's brain. Therefore, while the treatment lasts, "communication" with the TV and computer should be minimized.

To speed up the healing process, "forget" about the disease. Pay no attention to tics. If they are worried about the illness, explain that these troubles are temporary, they will soon pass. Children who suffer from tics become very vulnerable. They need to be helped to feel secure in order to be confident in their abilities.

Relieve tension with a relaxing massage, baths with pine extracts, essential oils, sea salt. Conduct physiotherapy and aromatherapy sessions for children.

• Actual information:

Medication treatment is the last option for solving the problem of hyperkinesis in children. It must be applied when the previous methods were powerless.

But deciding on treatment medicines, self-treatment is excluded. Even if they say that it helped someone with such a problem, this does not mean that it will help everyone.

In drug treatment, two groups of drugs are used: antidepressants (paxil) and antipsychotics or antipsychotics (tiapridal, teralen); they minimize the symptoms of motor phenomena - this is the basic treatment. But there may be more additional drugs. They are designed to improve metabolic processes in the brain, provide additionally necessary vitamins.

Complications

Vocal tics belong to the group neurological diseases and have a variety of reasons. Most often develop in childhood and over time can either disappear or develop into chronic form, weakening and strengthening. Vocal disorders are included in the group of neuroses, and the most common cause of their occurrence is the impact of stress on the emotional and mental component.

There are 2 groups of vocal tics that differ from each other in complexity and symptoms:

• Simple forms. This category includes tics, main symptom which are involuntary sounds: whistling, gnashing, clattering, yelping or coughing, as well as croaking and other similar sounds. They do not last long, can be combined with motor tics.
• complex forms. Such vocal tics may appear as shouts of entire phrases or individual words. Tourette's syndrome is a congenital disorder that accompanies the patient all his life and delivers severe discomfort. Complex tics are often associated with motor disturbances.

Among the causes of vocal tics, experts distinguish several groups of factors.

Causes of tics

Most vocal tics begin in childhood and remain with the child for some time. The hereditary factor affects the predisposition to this deviation. But the mechanisms of pathology are somewhat different:

• neuroses and experiences;
• excessive fatigue;
• strong fear, fright - one of the key mechanisms for triggering a tick;
• stress and nervous exhaustion;
• abuse of games on computers, smartphones;
• great emotional and psychological stress at school;
• secondary causes are diseases: brain pathologies, injuries, metabolic disorders, circulatory diseases.

In adults, tics provoke overstrain at work, family problems, and nervous exhaustion.

Important! Exposure can provoke a tick carbon dioxide, certain medications, and long-term alcohol use.

Other causes are often distinguished: head injuries received during childbirth, VVD.

Things are more complicated with hereditary causes. Children prone to vocal or mimic disorders begin to suffer from tics with the constant action of bad ecology.

There is also a higher risk of getting a disorder when autoimmune disorders or infections- from influenza and SARS to tuberculosis. Pathology is activated when there is an imbalance of vitamins and minerals in the body, especially magnesium and B6.

Possible manifestations of tics

Vocal tics in children are associated with several groups of symptoms. All of them start from the main symptom of a neurological disorder - the involuntary pronunciation of sounds or dreams. Here is how the disease manifests itself:

• coprolalia - the child utters obscene phrases, words;
• echolalia - the same word is constantly repeated;
• palilalia - speech becomes illegible, in some places there is a cyclicity, sometimes there is no relationship in what was said;
• slurred speech - a child or adult grits his teeth and speaks through them.

The first signs of vocal tics appear in preschool age- at the age of 5-7 years. If the violation occurred earlier, this may indicate serious diseases of the organs or nervous system.

Symptoms of pathology may include other conditions: sniffing, coughing, biting nails or hair.

Tourette syndrome

A separate hereditary manifestation of vocal tics - Tourette syndrome. Pathology is not subject complete cure, appears aggressively. In adults, the first signs are never found.

The syndrome belongs to the group of complex generalized tics, it can cover motor attacks, swearing, compulsive actions, as well as other motor and sound phenomena. The prevalence of the disorder is low - only 0.05% of the population throughout the Earth has this pathology identified.

The development of the disease occurs at the age of 2-5 years, rarely manifests itself at 13-18 years. Activation of the syndrome is associated with strong emotional and nervous experiences. Approximately 2/3 of cases are found in male adolescents.

Fact! Tourette syndrome was discovered by a French neurologist, after whom the disease was named.

Vocal-motor tic is included in the group of unexplained hereditary disorders. Even in the Middle Ages there were cases of pathology. The syndrome is usually treated by psychotherapists and neurologists.

Detailed Causes of Tourette's Disease

Via PAT and MRI brain, scientists were able to prove that a defect inherited from one of the parents is associated with a change in the correct structure of the basal ganglia, neurotransmitter and neurotransmitter spheres.

Doctors suggest that the increased secretion of dopamine leads to the appearance of pathology. Another theory believes that the role is not in the production of dopamine, but in the sensitivity of receptors. human body to him. In the treatment of tics, almost complete suppression of symptoms is observed after the use of dopamine receptor antagonists.

Medical therapy

All vocal tics require a multicomponent approach to treatment, especially Tourette's syndrome. If such a diagnosis is not made, doctors recommend paying attention to the patient's lifestyle:

• it is necessary to normalize the conditions of rest and work, as well as the regime - a child needs to sleep at least 8 hours, an adult - at least 7;
• you can’t constantly be at a computer, tablet, smartphone - 2 hours before bedtime, you need to give up games and entertainment;
• the patient must eat right, the diet is balanced, with vegetables, meat, fruits and nuts, without too fatty foods;
• moderate physical exercise should bring pleasure, not exhaust;
• you need to try to reduce the level of stress and tension;
• if the pathology of the baby appeared as a result of constant quarrels of the parents, they should reconsider their attitude.

Among the medicines for correcting vocal tics, B vitamins, magnesium and calcium are used.

Important! To correct the reaction, Biotredin, Glycine, as well as more powerful psychotropic substances Diazepam or Phenibut are used.

To relieve tension and irritation, you may need herbal preparations type "Novo-Passita". Physiotherapeutic procedures reinforce the effect of medicines: electrosleep, stone therapy, acupuncture, therapeutic massage.

Vocal tics are usually associated with hereditary factors, Tourette syndrome is one of the most severe forms pathology. It is necessary to treat vocal disorders, but this should be done by a doctor.

Vocal tic in adults and children is a neurological disorder that manifests itself in the form of involuntary sounds or involuntary pronunciation of words. This is one of the manifestations of a systemic neurosis. Vocal tics in children lead to a disruption in the learning process and are often a hindrance to socialization among peers. He is engaged in the treatment of this pathology.

Manifestations of vocal tics

Vocal tic in a child is a symptom of a complex neurotic disorder. Manifested in involuntary pronunciation of sounds, coughing, sniffing, sniffling. Often this disorder is combined with attention deficit disorder, other manifestations of neurosis. The child is able to control his behavior for some time, but this leads to increased stress on the nervous system.

A vocal tic in a child, whose symptoms can vary, can manifest itself in the following:

1. Coprolalia: the child involuntarily utters obscene and abusive words.
2. Echolalia is the repetition of the same word.
3. Palilalia - unintelligible, confused, fast speech.
4. Unclear speech through the teeth in Tourette's syndrome (see).

Most often, vocal tics are observed in preschool or younger children. school age. However, they also occur in adolescents and even adults.

Usually their attacks are preceded by nervous strain or mental fatigue. Although sometimes all that is required to stop the tics is to distract the child with some kind of entertainment, game or task. The disorder can seriously harm relationships with classmates at school or peers in kindergarten.

As well as speech disorders, possible, stuttering, restlessness in the classroom, enuresis, attention deficit disorder, muscle twitching (fasciculations). The disease interferes with concentration on studies. Manifestations may include coughing, sniffing, checking voice. In addition, children can bite their nails and hair. Symptoms get worse, usually towards the end of the day.

Causes

Vocal tics in adult children are associated with neurological pathology. The main causes of these disorders are:

1. neurotic states.
2. Traumatic brain injury.
3. Birth trauma.
4. Brain diseases (Tourette's syndrome, extrapyramidal disorders - hyperkinesis: chorea, athetosis).
5. Deficiency of vitamins and microelements along with the abuse of glutamate-containing drugs.

Traumatic brain and birth injuries can damage the centers of the brain associated with speech reproduction. Vocal tics can also be one of the symptoms of organic brain damage in extrapyramidal disorders, epilepsy, multiple sclerosis. Sometimes this is a manifestation of intoxication. This disrupts transmission. nerve impulses and the cerebral cortex is overexcited.

Neuroses caused by unsettled environment at home or at school can also cause disorders of the nervous system, leading to vocal tics. Family scandals, bad relationships with classmates or classmates can provoke confused speech, pronunciation of unwanted sounds.

Often these disorders appear against the background of nervous exhaustion: neurasthenic disorders or psychological trauma. Sometimes the condition is preceded by the death of close relatives or the experience of severe stress: acute or chronic.

A disorder may occur with a deficiency of important trace elements, leading to damage to the nervous system. Deficiency of B vitamins, especially B6, B1, B12, magnesium, calcium and potassium contributes to the disruption of nerve impulses.

Diagnosis and treatment of vocal tics

If vocal tics are detected, a visit to a neurologist should be made. Instrumental examinations include MRI of the brain or ultrasound, electroencephalogram to exclude organic pathologies. When sniffing and correcting the voice, diseases of the ENT organs are excluded.

At neurotic states it is necessary to build the daily routine of patients in such a way as to ensure good sleep. Should not be allowed nervous tension, mental overload, thereby preventing vocal tics in children whose treatment is complex problem. It is also necessary to avoid foods that provoke overexcitation of the nervous system: chocolate, tea and coffee, cocoa.

With vocal tics in children, the study load is mitigated, stress factors are eliminated in the learning process, as much as possible. class teacher or teacher kindergarten must be warned of the seriousness nervous breakdown The child has. If possible, the student can be transferred to home schooling. If you have voice tics, you should take soothing baths with aromatic oils: lavender, coniferous. Adults are advised to take a vacation and relax in a sanatorium.

Medical therapy

Additionally, vitamins and minerals containing vitamins B1, B6, B12, as well as calcium, magnesium, potassium. They contribute to the improvement of the activity of the nervous system, the elimination of its overexcitation.

To calm excess activity, drugs such as Biotredin are used. They contain inhibitory mediators of the nervous system, reducing its overexcitation. Phenibut, Picamilon affect receptors for gamma-aminobutyric acid, which calms the psyche and improves falling asleep, normalizes sleep.

Body massage, acupuncture reduce stress and are carried out in evening time, better before bedtime. Physiotherapy in daytime It will help to throw out muffled emotions, thereby reducing stress.

Conclusion

Speech disorders can be corrected and go away by themselves with growing up, but in any case, psychological and psychological support should be provided. medical assistance. How vocal tics appear in Tourette's syndrome, see the video.

Tics (hyperkinesis) are fast, repetitive involuntary arrhythmic movements, usually involving a specific muscle group. As a rule, they occur in children and occupy one of the leading places among diseases of the nervous system in childhood. About 20% of children under the age of 10 suffer from this pathology, and boys get sick more often and more severely than girls. There are critical age periods when the likelihood of tics increases significantly. This occurs at 3 years and 7-10 years.

Types of ticks

According to the prevalence of the process, tics are local (occurring in one area), multiple and generalized.

Allocate vocal and motor (motor) tics, which can be complex and simple.

Motor simple hyperkinesis:

• non-rhythmic violent movements of the head (in the form of twitches);
• involuntary blinking, squinting of eyes;
• shrug-type shoulder movements;
• tension of the abdominal muscles with its subsequent retraction.

Motor complex hyperkinesis:

• repetition of certain gestures (echopraxia);
• vulgar gestures;
• jumping in place;
• inflicting blows on parts of one's own body.

Simple vocal tics:

• snorting, grunting;
• whistling;
• cough.

Complex vocal tics:

• echolalia (repetition of words, phrases, sounds heard by the patient);
• coprolalia (uncontrollable shouting of obscene words).

Causes of the disease

Stress and overwork contribute to the occurrence of tics in a child during the maturation of the nervous system.

Nervous tics may be primary or secondary. Important role in the origin of primary tics, burdened heredity is assigned. Their development is based on disorders of the maturation of motor control systems, which is associated with dysfunction of the basal ganglia. Primary tics are divided into transient (transient) and chronic (the symptoms of which persist for more than a year).

Secondary tics also occur against the background of dysfunction of the basal ganglia, but there is a primary pathological condition which led to this, namely:

• head injury;
• damage to the nervous system during childbirth;
• taking certain medications (neuroleptics, psychostimulants);
• inflammatory diseases of the substance of the brain;
• pathology of the brain of a vascular nature.

A certain role in the manifestation of tics is played by stress, mental overload, and an unfavorable situation in the family.

Features of the course of tics in children

This disease in each child can proceed differently. It can suddenly appear at some period of a child's life and disappear just as quickly even without treatment. And it can last for years with severe symptoms and changes in behavioral responses. Children with tics often have irritability, anxiety, inability to concentrate, impaired coordination of movements, etc.

Symptoms of the disease are aggravated by excitement and weakened by distraction, concentration on certain activities. If the child is interested or playing, the tics usually disappear. Patients can suppress the tics for a short period of time by willpower, but subsequently they arise with increasing force. The severity of such involuntary movements may vary depending on the mood and psycho-emotional state of the child, the season and even the day. This pathology is characterized by stereotyping and the occurrence of manifestations of the disease in a certain area of ​​the body, but over time, the localization of tics may change.

Tourette syndrome

This is a disease of the nervous system, which is characterized by a combination of motor and vocal tics in a child. The onset of the disease occurs between the ages of 5 and 15 years. The first to appear are tics on the face, then the muscles of the neck, arms, legs, and torso are involved in the pathological process. This pathology has a chronic progressive course and reaches its maximum development in adolescence, then the severity of symptoms weakens. In some patients, tics disappear without a trace, and in some patients they persist for life.

Children with manifestations of Tourette's syndrome are characterized by absent-mindedness, restlessness, distractibility, increased vulnerability, and sometimes aggressiveness. Half of the patients in adolescence a syndrome of obsession develops, which is manifested by unreasonable fears, obsessive thoughts and actions. These phenomena occur against the will of the patient, and he is unable to suppress them.

Diagnostics

The diagnosis is based on complaints of the patient or parents, medical history, neurological examination. Examination of the patient is recommended to rule out organic pathology. General clinical examination, electroencephalography, CT scan, MRI, psychiatric consultation, etc.

Treatment

In most cases, the disease has a benign course and does not require special treatment. Children need to create a favorable psychological environment in the family, avoid mental and physical overload. Rational nutrition and adequate sleep are of particular importance. Parents should not focus the attention of the child on the symptoms of the disease. Children with tics are advised to limit their use of the computer (especially computer games), listening to loud music, watching TV for a long time, reading books in low light and lying down.

The main therapeutic measures:

1. Psychotherapy (individual or group).
2. Physiotherapy.
3. Medical treatment:

• neuroleptics (eglonil, haloperidol);
• antidepressants (anafranil);
• nootropic drugs (noofen, phenibut, glycine);
• magnesium preparations (magne B6);
• vitamins.

Treatment with physical factors

Massotherapy helps the child to relax and reduces his excitability.

It helps to calm the child, normalize the work of his nervous system, reduces the manifestations of the disease.

The main physical treatments for children with tics are:

• (provides sedative action, normalizes emotional condition patients, improves blood supply to the brain tissue and metabolism; the duration of the procedure is about an hour, while the child is in a state of drowsiness, the course of treatment is 10-12 procedures);
• on the cervical-collar zone (has an indirect effect on the nervous system, reduces general excitability);
• (increases the body's resistance to stressful influences, improves mood and the functioning of the nervous system; session duration is 20-30 minutes, 10-12 such sessions are recommended);
• (calm, relax, improve sleep; you need to take such baths every other day).

Conclusion

The appearance of tics in a child is a reason for careful medical examination, since ticks can be initial manifestation more serious illness. The prognosis for recovery in most patients is favorable. However, in some patients, the disease does not completely regress. There is an opinion that with an early onset of the disease (especially at the age of 3 years), it has a more severe and prolonged course.

Neurologist Nikolai Zavadenko talks about nervous tics in children:

TV channel "Belarus 1", program "Children's Doctor", episode on the topic "Tics in children":

Tics, or hyperkinesias, are repetitive, unexpected, short, stereotyped movements or statements that are outwardly similar to voluntary actions. characteristic feature tics is their involuntariness, but in most cases the patient can reproduce or partially control his own hyperkinesis. At a normal level of intellectual development of children, the disease is often accompanied by cognitive impairments, motor stereotypes, and anxiety disorders.

The prevalence of tics reaches approximately 20% in the population.

Until now, there is no consensus on the occurrence of tics. The decisive role in the etiology of the disease is assigned to the subcortical nuclei - the caudate nucleus, the pale ball, the subthalamic nucleus, the substantia nigra. The subcortical structures closely interact with the reticular formation, the thalamus, the limbic system, the cerebellar hemispheres, and the frontal cortex of the dominant hemisphere. The activity of subcortical structures and frontal lobes regulated by the neurotransmitter dopamine. Insufficiency of the dopaminergic system leads to impaired attention, lack of self-regulation and behavioral inhibition, decreased control motor activity and the appearance of excessive, uncontrolled movements.

The effectiveness of the dopaminergic system can be affected by intrauterine development disorders due to hypoxia, infection, birth trauma, or hereditary insufficiency of dopamine metabolism. There are indications of an autosomal dominant type of inheritance; however, it is known that boys suffer from tics about 3 times more often than girls. Maybe, we are talking about cases of incomplete and sex-dependent gene penetration.

In most cases, the first appearance of tics in children is preceded by the action of external adverse factors. Up to 64% of tics in children are triggered by stressful situations- school maladaptation, additional training sessions, uncontrolled TV viewing or prolonged work on the computer, conflicts in the family and separation from one of the parents, hospitalization.

Simple motor tics can be observed in the long-term period of traumatic brain injury. Voice tics - coughing, sniffing, expectorating throat sounds - are often found in children who are often ill respiratory infections(bronchitis, tonsillitis, rhinitis).

In most patients, there is a daily and seasonal dependence of tics - they intensify in the evening and worsen in the autumn-winter period.

A separate type of hyperkinesis should include tics that occur as a result of involuntary imitation in some highly suggestible and impressionable children. This happens in the process of direct communication and subject to the well-known authority of a child with tics among peers. Such tics go away on their own some time after the cessation of communication, but in some cases such imitation is the debut of the disease.

Clinical classification of tics in children

By etiology

Primary, or hereditary, including Tourette's syndrome. The main type of inheritance is autosomal dominant with varying degrees of penetrance; sporadic cases of the onset of the disease are possible.

Secondary, or organic. Risk factors: anemia in pregnant women, mother's age over 30 years, fetal malnutrition, prematurity, birth trauma, previous brain injury.

Cryptogenic. Occur against the background of full health in a third of patients with tics.

According to clinical manifestations

Local (facies) tick. Hyperkinesias capture one muscle group, mainly mimic muscles; rapid blinking, squinting, twitching of the corners of the mouth and wings of the nose predominate (Table 1). Blinking is the most persistent of all localized tic disorders. Squinting is characterized by a more pronounced violation of tone (dystonic component). The movements of the wings of the nose, as a rule, join the rapid blinking and are intermittent symptoms of facial tics. Single facial tics practically do not interfere with patients and in most cases are not noticed by the patients themselves.

Common tic. Several muscle groups are involved in hyperkinesis: mimic, muscles of the head and neck, shoulder girdle, upper limbs, muscles of the abdomen and back. In most patients, a common tic begins with blinking, which is followed by the establishment of a gaze, turns and tilts of the head, and shoulder lifts. During periods of exacerbation of tics, schoolchildren may have problems completing written assignments.

Vocal tics. There are simple and complex vocal tics.

The clinical picture of simple vocal tics is represented mainly by low sounds: coughing, "clearing the throat", grunting, noisy breathing, sniffing. Less common are such high-pitched sounds as “i”, “a”, “u-u”, “uf”, “af”, “ay”, squeal and whistle. With exacerbation of tic hyperkinesis, vocal phenomena may change, for example, coughing turns into grunting or noisy breathing.

Complex vocal tics are observed in 6% of patients with Tourette's syndrome and are characterized by the pronunciation of individual words, swearing (coprolalia), repetition of words (echolalia), rapid uneven, slurred speech (palilalia). Echolalia is a non-permanent symptom and may occur over several weeks or months. Coprolalia is usually a status condition in the form of a serial utterance of curses. Often, coprolalia significantly limits social activity child, depriving him of the opportunity to attend school or public places. Palilalia is manifested by the obsessive repetition of the last word in a sentence.

Generalized tic (Tourette's syndrome). It is manifested by a combination of common motor and vocal simple and complex tics.

Table 1 presents the main types of motor tics, depending on their prevalence and clinical manifestations.

As can be seen from the presented table, with the complication of the clinical picture of hyperkinesis, from local to generalized, tics spread from top to bottom. So, with a local tic, violent movements are noted in the muscles of the face, with a widespread one they move to the neck and arms, with a generalized one, the torso and legs are involved in the process. Blinking occurs with the same frequency in all types of tics.

By gravity clinical picture

The severity of the clinical picture is assessed by the number of hyperkinesis in a child during 20 minutes of observation. In this case, ticks can be absent, single, serial or status ticks. Severity assessment is used to unify the clinical picture and determine the effectiveness of treatment.

At single ticks their number for 20 minutes of examination ranges from 2 to 9, they are more common in patients with local forms and in remission in patients with widespread tic and Tourette's syndrome.

At serial ticks in 20 minutes of examination, from 10 to 29 hyperkinesias are observed, after which there are many hours of breaks. A similar picture is typical during an exacerbation of the disease, occurs in any localization of hyperkinesis.

At tic status serial tics follow with a frequency of 30 to 120 or more per 20 minutes of examination without interruption during the day.

Like motor tics, vocal tics can also be single, serial and status tics; they intensify in the evening, after emotional stress and overwork.

According to the course of the disease

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), there are transient tics, chronic tics, and Tourette's syndrome.

transient , or transitory , the course of tics implies the presence of motor or vocal tics in a child with the complete disappearance of symptoms of the disease within 1 year. Typical for local and widespread tics.

Chronic A tic disorder is characterized by motor tics lasting more than 1 year without a vocal component. Chronic vocal tics in an isolated form are rare. There are remitting, stationary and progredient subtypes of the course of chronic tics.

With a relapsing course, periods of exacerbations are replaced by a complete regression of symptoms or the presence of local single ticks that occur against the background of intense emotional or intellectual stress. The relapsing subtype is the main variant of the course of tics. With local and widespread tics, exacerbation lasts from several weeks to 3 months, remissions last from 2-6 months to a year, in rare cases up to 5-6 years. On the background drug treatment complete or incomplete remission of hyperkinesis is possible.

The stationary type of the course of the disease is determined by the presence of persistent hyperkinesis in various groups muscles that persist for 2-3 years.

The progressive course is characterized by the absence of remissions, the transition of local tics to widespread or generalized ones, the complication of stereotypes and rituals, the development of tic statuses, and resistance to therapy. The progredient course predominates in boys with hereditary tics. Unfavorable signs are the presence of aggressiveness, coprolalia, obsessions in a child.

There is a relationship between the location of tics and the course of the disease. So, for a local tic, a transient-remitting type of flow is characteristic, for a common tic - remitting-stationary, for Tourette's syndrome - remitting-progressive.

Age dynamics of tics

Most often, tics appear in children aged 2 to 17 years, the average age is 6-7 years, the frequency of occurrence in the child population is 6-10%. Most children (96%) develop tics before the age of 11 years. The most common manifestation of tics is eye blinking. At the age of 8-10 years, vocal tics appear, which make up about a third of cases of all tics in children and occur both independently and against the background of motor tics. More often, the initial manifestations of vocal tics are sniffing and coughing. The disease is characterized by an increasing course with a peak of manifestations at 10-12 years, then a decrease in symptoms is noted. By the age of 18, approximately 50% of patients are spontaneously free of tics. At the same time, there is no relationship between the severity of tics in childhood and adulthood, but in most cases, in adults, the manifestations of hyperkinesis are less pronounced. Sometimes tics first occur in adults, but they are milder and usually last no more than 1 year.

The prognosis for local tics is favorable in 90% of cases. In the case of widespread tics, 50% of children have a complete regression of symptoms.

Tourette syndrome

The most severe form of hyperkinesis in children is, without a doubt, Tourette's syndrome. Its frequency is 1 case per 1000 of the child population in boys and 1 in 10,000 in girls. The syndrome was first described by Gilles de la Tourette in 1882 as "a disease of multiple tics". The clinical picture includes motor and vocal tics, attention deficit disorder, and obsessive-compulsive disorder. The syndrome is inherited with high penetrate in an autosomal dominant manner, and in boys tics are more often combined with attention deficit hyperactivity disorder, and in girls with obsessive-compulsive disorder.

The currently accepted criteria for Tourette's syndrome are those given in the DSM classification III revision. Let's list them.

• A combination of motor and vocal tics that occur simultaneously or at different time intervals.
• Repeated tics throughout the day (usually in series).
• The location, number, frequency, complexity, and severity of tics change over time.
• The onset of the disease is up to 18 years, the duration is more than 1 year.
• Symptoms of the disease are not related to the intake psychotropic drugs or CNS disease (Huntington's chorea, viral encephalitis, systemic diseases).

The clinical picture of Tourette's syndrome depends on the age of the patient. Knowledge of the basic patterns of the development of the disease helps to choose the right treatment tactics.

Debut The disease develops at 3-7 years of age. The first symptoms are local facial tics and twitching of the shoulders. Then hyperkinesias spread to the upper and lower limbs, there are shudders and turns of the head, flexion and extension of the hand and fingers, tilting the head back, contraction of the abdominal muscles, bouncing and squatting, one type of tick is replaced by another. Vocal tics often join motor symptoms within a few years after the onset of the disease and increase in the acute stage. In a number of patients, vocalisms are the first manifestations of Tourette's syndrome, which are subsequently joined by motor hyperkinesis.

Generalization of tic hyperkinesis occurs over a period of several months to 4 years. At the age of 8-11 years, children have peak of clinical manifestations of symptoms in the form of a series of hyperkinesias or repeated hyperkinetic statuses in combination with ritual actions and autoaggression. The tic status in Tourette's syndrome characterizes a severe hyperkinetic state. A series of hyperkinesis is characterized by the change of motor tics to vocal ones, followed by the appearance of ritual movements. Patients report discomfort from excessive movement, such as pain in cervical region spine, which occurs against the background of head turns. The most severe hyperkinesis is a tilting of the head - while the patient can repeatedly hit the back of the head against the wall, often in combination with simultaneous clonic twitching of the arms and legs and the appearance of muscle pain in the extremities. The duration of status ticks ranges from several days to several weeks. In some cases, exclusively motor or predominantly vocal tics (coprolalia) are noted. During status tics, consciousness in children is completely preserved, however, hyperkinesis is not controlled by patients. During exacerbations of the disease, children cannot attend school, they find it difficult to self-service. Characteristically relapsing current with exacerbations lasting from 2 to 12-14 months and incomplete remissions from several weeks to 2-3 months. The duration of exacerbations and remissions is directly dependent on the severity of tics.

In most patients at the age of 12-15, generalized hyperkinesias pass into residual phase , manifested by local or widespread tics. In a third of patients with Tourette's syndrome without obsessive-compulsive disorders in the residual stage, a complete cessation of tics is observed, which can be considered as age-dependent. infantile form diseases.

Comorbidity of tics in children

Tics often occur in children with pre-existing central nervous system (CNS) disorders such as attention deficit hyperactivity disorder (ADHD), cerebrovascular disorder, and anxiety disorders including generalized anxiety disorder, specific phobias, and obsessive-compulsive disorder.

Approximately 11% of children with ADHD have tics. Mostly these are simple motor and vocal tics with a chronic relapsing course and a favorable prognosis. In some cases, the differential diagnosis between ADHD and Tourette's syndrome is difficult, when hyperactivity and impulsivity appear in a child before the development of hyperkinesis.

In children with generalized anxiety disorder or specific phobias, tics can be provoked or exacerbated by worries and experiences, an unusual environment, a long wait for an event and an accompanying increase in psycho-emotional stress.

In children with obsessive-compulsive disorder, vocal and motor tics are associated with obsessive repetition any movement or activity. Apparently, in children with anxiety disorders, tics are an additional, albeit pathological form of psychomotor discharge, a way of calming and “processing” accumulated internal discomfort.

Cerebrosthenic syndrome in childhood is the result of traumatic brain injuries or neuroinfections. The appearance or intensification of tics in children with cerebrasthenic syndrome is often provoked external factors: heat, stuffiness, change in barometric pressure. Characterized by an increase in tics with fatigue, after prolonged or repeated somatic and infectious diseases, an increase in training loads.

We present our own data. Of the 52 children who complained of tics, there were 44 boys, 7 girls; the ratio "boys: girls" was "6: 1" (Table 2).

So, the greatest number of appeals for tics was noted in boys aged 5-10 years, with a peak at 7-8 years. The clinical picture of ticks is presented in Table. 3.

Thus, simple motor tics with localization mainly in the muscles of the face and neck and simple vocal tics imitating physiological actions (cough, expectoration) were most often noted. Jumping and complex vocal utterances were much less common, only in children with Tourette's syndrome.

Temporary (transient) tics lasting less than 1 year were observed more often than chronic (remitting or stationary). Tourette's syndrome (chronic stationary generalized tic) was observed in 7 children (5 boys and 2 girls) (Table 4).

Treatment

The main principle of therapy for tics in children is a comprehensive and differentiated approach to treatment. Before prescribing medication or other therapy, it is necessary to find out possible reasons the occurrence of the disease and discuss with parents ways of pedagogical correction. It is necessary to explain the involuntary nature of hyperkinesis, the impossibility of controlling them by willpower and, as a result, the inadmissibility of remarks to the child about tics. Often, the severity of tics decreases with a decrease in the requirements for the child on the part of the parents, the absence of fixing attention on his shortcomings, the perception of his personality as a whole, without isolating "good" and "bad" qualities. The therapeutic effect is exerted by streamlining the regimen, playing sports, especially on fresh air. If induced tics are suspected, the help of a psychotherapist is necessary, since such hyperkinesias are removed by suggestion.

When deciding on the appointment of drug treatment, it is necessary to take into account such factors as the etiology, age of the patient, the severity and severity of tics, their nature, concomitant diseases. Drug treatment should be carried out with severe, pronounced, persistent tics, combined with behavioral disorders, school failure, affecting the child's well-being, complicating his adaptation in the team, limiting his opportunities for self-realization. Drug therapy should not be given if the tics are only a concern for the parents but do not interfere with the child's normal activities.

The main group of drugs prescribed for tics are neuroleptics: haloperidol, pimozide, fluphenazine, tiapride, risperidone. Their effectiveness in the treatment of hyperkinesis reaches 80%. The drugs have analgesic, anticonvulsant, antihistamine, antiemetic, neuroleptic, antipsychotic, sedative effects. The mechanisms of their action include blockade of postsynaptic dopaminergic receptors of the limbic system, hypothalamus, trigger zone of the gag reflex, extrapyramidal system, inhibition of dopamine reuptake by the presynaptic membrane and subsequent deposition, as well as blockade of adrenoreceptors of the reticular formation of the brain. Side effects: headache, drowsiness, impaired concentration, dry mouth, increased appetite, agitation, anxiety, anxiety, fear. At long-term use extrapyramidal disorders may develop, including increased muscle tone, tremor, akinesia.

Haloperidol: Initial dose is 0.5 mg at night, then increased by 0.5 mg per week until therapeutic effect(1-3 mg / day in 2 divided doses).

Pimozide (Orap) is comparable in effectiveness to haloperidol, but has fewer side effects. The initial dose is 2 mg / day in 2 doses, if necessary, the dose is increased by 2 mg per week, but not more than 10 mg / day.

Fluphenazine is prescribed at a dose of 1 mg / day, then the dose is increased by 1 mg per week to 2-6 mg / day.

Risperidone belongs to the group of atypical antipsychotics. The effectiveness of risperidone in tics and related behavioral disorders, especially oppositional defiant ones, is known. The initial dose is 0.5-1 mg / day with a gradual increase until a positive trend is achieved.

When choosing a drug for the treatment of a child with tics, the most convenient form of release for dosing should be considered. Optimum for titration and subsequent treatment in childhood are drip forms (haloperidol, risperidone), which allow you to most accurately select the maintenance dose and avoid unjustified drug overdose, which is especially important during long courses of treatment. Preference is also given to drugs with a relatively low risk of side effects (risperidone, tiapride).

Metoclopramide (Reglan, Cerucal) is a specific blocker of dopamine and serotonin receptors in the trigger zone of the brainstem. With Tourette's syndrome in children, it is used at a dose of 5-10 mg per day (1/2-1 tablet), in 2-3 doses. Side effects- extrapyramidal disorders, manifested when the dose is exceeded 0.5 mg / kg / day.

In recent years, valproic acid preparations have been used to treat hyperkinesis. The main mechanism of action of valproates is to enhance the synthesis and release of γ-aminobutyric acid, which is an inhibitory mediator of the central nervous system. Valproates are the drugs of first choice in the treatment of epilepsy, however, their thymoleptic effect is of interest, which manifests itself in a decrease in hyperactivity, aggressiveness, irritability, as well as a positive effect on the severity of hyperkinesis. The therapeutic dose recommended for the treatment of hyperkinesis is significantly lower than for the treatment of epilepsy and is 20 mg/kg/day. Side effects include drowsiness, weight gain, and hair loss.

When hyperkinesis is combined with obsessive-compulsive disorder, antidepressants - clomipramine, fluoxetine - have a positive effect.

Clomipramine (Anafranil, Clominal, Clofranil) is a tricyclic antidepressant, the mechanism of action is inhibition of the reuptake of norepinephrine and serotonin. The recommended dose in children with tics is 3 mg/kg/day. Side effects include transient visual disturbances, dry mouth, nausea, urinary retention, headache, dizziness, insomnia, irritability, extrapyramidal disorders.

Fluoxetine (Prozac) is an antidepressant drug, a selective serotonin reuptake inhibitor with low activity in relation to the norepinephrine and dopaminergic systems of the brain. In children with Tourette's syndrome, it eliminates anxiety, anxiety, and fear well. The initial dose in childhood is 5 mg / day 1 time per day, the effective dose is 10-20 mg / day 1 time in the morning. Tolerability of the drug is generally good, side effects occur relatively rarely. Among them, the most significant are anxiety, sleep disorders, asthenic syndrome, sweating, weight loss. The drug is also effective in combination with pimozide.

Literature

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N. Yu. Suvorinova, Candidate of Medical Sciences
RSMU, Moscow