Paediatric Dietitians – referral criteria
This guidance is for GPs who have seen a child with new or troubling motor tics. A motor tic is defined as ‘fast, repetitive muscle movements that result in sudden and difficult to control body jolts or sounds’. They are very common in children from the age of 5 years and above and it is estimated that 20% of children experience motor tics at some point. The majority of these subside without the need for any intervention. Tics of less than a year duration are termed ‘transient tic disorder’.
Vocal tics may also occur and are frequently termed ‘Tourettes’ syndrome.
History taking:
- Duration of symptoms (over a year is termed a ‘persistent tic disorder’)
- Parents may have videos of the abnormal movements.
- Features of seizures including urinary incontinence, loss of consciousness, tongue biting, post ictal phase, so important to ask, in order to help exclude seizures.
- Any triggers to include specific stressors.
- Onset of symptoms – abrupt or gradual?
- Any co morbid conditions – children with persistent tics may also have co morbidity with anxiety, OCD or ADHD. Have there been concerns raised from other adults eg: school?
- Are there any unwanted effects of persistent tics eg: muscle pain and need for analgesia?
Examination:
Should include a neurological examination, which should be normal in a motor tic disorder.
Evidence of deliberate self harm should be sought (?evidence of cutting).
There are very few ‘Red Flags’ for a motor tic.
- Evidence of deliberate self harm or suicidal ideation needs urgent CAMHS assessment.
- Abnormal neurological examination – may need urgent paediatric review. We are happy to discuss the urgency of review via the Consultant held telephone Mon-Fri 9-5, via switchboard (0208 546 7711).
In most children and young people, motor tics subside on their own without medical intervention. It is important that parents are reassured, that tics are common and the majority of tics subside without the need for referral or therapy. In persistent tics lasting > 1 year, families may need help managing the tics and any associated co morbidities.
These are not generally managed by General Paediatrics, unless there is a very abrupt (overnight) onset, or any abnormal neurological findings.
In the absence of any ‘Red Flags’, families should be given reassurance that most motor tics resolve, and advice for avenues of support. Reducing any stressors, and advocating techniques to help relieve stress are key. These may involve yoga, mindfulness and relaxation techniques. The Tourettes Action website is listed under ‘Supporting Information’ and has helpful suggestions for parents.
Persistent tics can be referred according to the child’s home postcode to:
- Lisa Davies, CAMHS Consultant at Woodroffe House in Tolworth for Children with a Kingston postcode. They have a psychologist trained in the CBiT for persistent and troubling tics who can provide therapy as needed.
- For other children, Dr Helen Simmons, Consultant Neurologist at St Georges Hospital has an interest in tics, for children outside the Kingston area. She does not accept referrals directly from Primary Care, so would need a general paediatrics referral first (via ERS) and we can consider onwards referral, if considered appropriate.
- For young people aged 16 years and over, there is a specific tic clinic at St Georges Hospital who can provide assessment and support for young people with persistent tics.
Details here: Tourette Syndrome – St George’s University Hospitals NHS Foundation Trust (stgeorges.nhs.uk)
If you are unsure which is the best route, we are happy to discuss via Advice & Guidance on ERS or the non urgent Consultant held advice line (via switchboard, Mon-Fri 9-5).
Parents may find the Tourettes Action website helpful, but it is important to emphasise that Tourettes specifically refers to vocal tics. However, the strategies they suggest may also be helpful in managing motor tics.