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Paediatric tic-like presentations during the COVID-19 pandemic
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  1. Sarah Buts1,
  2. Morvwen Duncan2,
  3. Tamsin Owen1,
  4. Davide Martino3,
  5. Tamara Pringsheim3,
  6. Susan Byrne1,4,
  7. Andrew McWilliams2,5,
  8. Tara Murphy2,
  9. Osman Malik1,4,
  10. Holan Liang2,
  11. Isobel Heyman6,
  12. Tammy Hedderly1,4
  1. 1Evelina London Children's Hospital Neurosciences Department, London, UK
  2. 2Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children, London, London, UK
  3. 3Alberta Children's Hospital, Calgary, Alberta, Canada
  4. 4Child Health Clinical Academic Group, King's College London, London, UK
  5. 5Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
  6. 6UCL Great Ormond Street Institute of Child Health Population Policy and Practice, London, UK
  1. Correspondence to Dr Tammy Hedderly, Evelina London Children's Hospital Neurosciences Department, London SE1 9RT, UK; Tammy.Hedderly{at}gstt.nhs.uk

Abstract

Background and aim Clinical centres have seen an increase in tic-like movements during the COVID-19 pandemic. A series of children and adolescents are described.

Methods A retrospective chart review of 34 consecutive paediatric patients presenting with sudden onset tic-like movements, seen over 6 months.

Results 94% of patients were female, with an average age of sudden onset or increase of tic-like movements of 13.7 years. 44% had a previous diagnosis of tics, and 47% initially presented to an emergency department. Comorbid psychiatric and neurodevelopmental disorders were reported in 91% with 68% reporting anxiety.

Conclusion We highlight a dramatic presentation of sudden onset functional tic-like movements in predominantly female adolescents to help inform identification and management. There is need to research the neurobiological underpinnings and environmental exacerbating factors leading to these presentations and to explore effective therapeutic strategies.

  • child psychiatry
  • adolescent health
  • paediatric emergency medicine
  • neurology
  • psychology

Data availability statement

Data may be obtained from a third party and are not publicly available. Anonymised tables with data of 34 patients is available at specific request from TH via tammy.hedderly@gstt.nhs.uk.

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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What is already known on this topic?

  • During the COVID-19 pandemic, a significant increase in incidence of tics and functional tic-like episodes in children and adolescents has been reported.

  • There has been a worsening of mental health in children and young people in association with the pandemic.

What this study adds?

  • A description of the demographic and clinical characteristics of children and adolescents presenting with tic-like movements during the COVID-19 pandemic.

  • The patient characteristics, including clinical history, symptoms and associations highlight a need to consider diagnosis of functional movements that can mimic tics.

  • We report a subgroup that presents with patterns of complex tic-like movements/sounds similar to those seen in social media videos.

Introduction

Viewpoint papers have emerged internationally reporting an increase in functional tic-like movements, seemingly coincident with the COVID-19 pandemic. The patients described presented with sudden onset, often complex tic-like movements, which appear functional in nature rather than part of a chronic tic disorder (CTD) or Tourette syndrome (TS). The diagnosis of functional tic-like movements can be challenging. Criteria that differentiate functional from other movement disorders (distractibility and suggestibility) are clinical features also seen in tics.1 Though pathophysiology of functional tic-like movements and tics is different, shared pathways are likely considering the overlapping features.2 As medications used for tics are usually ineffective in functional tic-like movements,1 it is important to differentiate the two.

The pandemic could have impacted negatively on the mental health of young people with existing mental health and/or neurodevelopmental difficulties through biopsychosocial factors including worry, illness/bereavement, loss of routine, domestic factors and social isolation.

The aim of this case series is to describe the clinical characteristics of children presenting with sudden onset or escalation of functional tic-like movements during the COVID-19 pandemic to allow for earlier recognition and accurate diagnosis.

Methods

This is a retrospective case note review of children assessed between November 2020 and April 2021 in tic clinics in the UK (Evelina London Children’s Hospital ELCH and Great Ormond Street Hospital (GOSH) London) and Canada (Alberta Children’s in Calgary). Criteria for inclusion were: (A) Sudden onset or increase of possible tics or tic-like movements within a period of less than 5 days and (B) age 8–17 years.

A multidisciplinary team assessed children and screened for co-occurring conditions using interviews and screening questionnaires. All children were administered the Yale Global Tic Severity Scale (YGTSS) and the Children’s Global Assessment Scale (CGAS). Previously diagnosed psychiatric and neurodevelopmental co-occurring conditions were recorded as reported by parents/guardians. In a subgroup of patients at Calgary and GOSH, Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5) criteria were used.

Statistical analysis was performed with SPSS V.25. Frequencies and percentages were used for categorical variables; depending on their distribution, mean and SD or median and range were used for dimensional variables.

Results

A total of 34 children were evaluated with most participants being female (94%) and Caucasian (79%). The average age at presentation was 13.7 (SD 2), respectively, 13 (SD 2.5) and 14 (SD 1.6) years for patients with (44%) and without (56%) previous tic diagnosis.

Table 1 shows the differences between patient and clinical characteristics seen in this case series, compared with frequencies previously described in CTD/TS research. In this series, there is a high female preponderance, late age of onset, low prevalence of wax-and-wane pattern and high prevalence of pali/echo/copro-phenomena compared with CTDs/TS.

Table 1

Pointers to clinically differentiate tics from functional tic-like movements (both can coincide)

The YGTSS total tic severity score is high in this series compared with previous tic research. The perceived severity is also indicated by the high proportion of these patients (47%) who presented to the emergency department with abnormal movements, 44% (7/16) of them receiving acute medication. Another indication of the impact of these movements is shown through the low mean CGAS of 45 (range 35–75) in this series.

Psychiatric and neurodevelopmental comorbidities were reported in 91%, depicted in figure 1. In this series anxiety was the most common comorbidity, reported in 68% and diagnosed in clinic in 50%. Depression was reported in 24%.

Figure 1

Pre-existing psychiatric and neurodevelopmental comorbidities of 34 patients presenting with functional tic-like movements to specialist tic clinics (1 October 2020–30 April 2021). Permission for the reuse of this figure was granted by MD and SB.

There were high rates of clinical diagnoses of Attention Deficit Hyperactivity Disorder (ADHD) (57%) and autism spectrum disorder (ASD) (50%) in 14 GOSH patients. A family history of tics was reported in 29% of patients.

In only 15% of cases there was a reported past positive COVID-19 test either in the patient or in their first-degree family members. None reported being medically unwell with COVID-19.

Seventy-seven per cent of patients reported watching videos of ‘tics’ on social media, mostly prior to onset of symptoms. Fourteen participants presented with a characteristic pattern of movements almost identical to those seen in social media videos, including at least two of the following: thumping chest, slapping own and/or parents’ head, clapping hands, whistling, head nod and copro-, pali- or echolalia. In 56% of cases, there were other people in the environment with presentation of tics/tic-like movements.

Discussion

Functional tic-like movements, based on previous case series with adults, have been characterised by a female preponderance, late age of onset, lack of premonitory urge, suppressibility and wax-and-wane pattern with an absence of a family history of tics.1 In this paediatric sample, these patterns were similar, with some exceptions. There is a high percentage of copro-phenomena compared with other studies. Premonitory urge and suppressibility are still common. This study lacks qualitative data, and we can thus not differentiate the types of urges in this series from those described in patients with CTDs. Family history of tics is also common in this series. Along with previous history of tics in 44%, this points towards an overlapping phenomenon between tics and functional tic-like movements. This is unsurprising given the overlap of pathophysiological features as well as the common prevalence of psychiatric and neurodevelopmental comorbidities in both disorders.3 The particularly high prevalence of anxiety and ASD in this case series suggest that these are associated with functional tic-like movements.

What has contributed to or caused such a sudden increase in presentation of functional tic-like movements? Factors such as social isolation, difficulty with adjusting to online schooling and loss of routine in relation to the pandemic have been proposed. Unrecognised and unsupported ASD and/or ADHD can lead to increased anxiety in everyday life, which can be compounded by pandemic-related stress.

Social media apps promoting the sharing of videos of tic-like movements could play a part in the escalation of sudden onset movements. Mechanisms for this ‘imitation’ phenomena could include echophenomena with suggestibility and some sort of neurological mimicry. Peer support and a sense of belonging gained by watching or posting videos of tics were reported in some cases, which may inadvertently reinforce symptoms. Underlying neurobiological and genetic factors are likely to interact. An international collaboration has been proposed to further explore potential mechanisms.

Once a diagnosis of functional tic-like movements is made, management may include psychoeducation with an integration of neurological and mental healthcare. It is important to ensure children and families understand the diagnosis and the usefulness of psychological support and intervention when necessary. The aims of management should be to prevent adverse impact on socialisation, education and emotional functioning in the context of the pandemic. Psychoeducation and general well-being support can result in a dramatic resolution of symptoms. The long-term prognosis of functional neurological presentations is not yet known.

As a small case series, this study has inevitable limitations. One limitation is that psychiatric and neurodevelopmental comorbidities were reported and not diagnosed in all cases. Furthermore, only tertiary specialist centres were involved, and cases might not be representative of the wider UK experience.

Conclusion

This case series highlights a group of predominantly teenage girls presenting with sudden onset functional tic-like movements. This may be one of the less well-recognised increased mental health presentations temporally associated with the COVID-19 pandemic, most likely resulting from multiple biopsychosocial factors that are yet to be fully identified. The role of social media, neurogenetic vulnerability and neurodevelopmental factors will be a subject of further research. Elucidation of the potential mechanisms involved in the emergence of this presentation will aim to inform future management options.

Data availability statement

Data may be obtained from a third party and are not publicly available. Anonymised tables with data of 34 patients is available at specific request from TH via tammy.hedderly@gstt.nhs.uk.

Ethics statements

Patient consent for publication

Ethics approval

The study was approved by the ethics committees.

Acknowledgments

All research at Great Ormond Street Hospital National Health Service Foundation Trust and University College London Great Ormond Street Institute of Child Health is made possible by the National Institute for Health Research (NIHR) Great Ormond Street Hospital Biomedical Research Centre.

References

Footnotes

  • Contributors All coauthors contributed to the data collection and writing of the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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