Homoeopathic indications for tics in children

Dr Edalissa Kharraswai

ABSTRACT
Tics occur most often in school-going children and usually represent emotional disturbance or mal adjustment. Generally, they may be an outlet for the suppressed anger and worrisome following control of aggression by the parents or the teacher. It is characterized by sudden brief non-rhythmic, rapid, repetitive, involuntary movements of various parts of the body. Children suffering with tics may report an interference with daily activities. This article provides an overview of the types of tics, clinical course and its management with homoeopathic indications.

KEYWORDS: Tic disorders, Tourette disorder, persistent motor or vocal tic disorder, provisional tic disorder, homeopathic management

INTRODUCTION
Tourette disorder (TD), persistent (chronic) motor or vocal tic disorder (PTD), and provisional tic disorders are the main tic disorders which is characterized by involuntary, rapid, repetitive, single or multiple motor and/or vocal/phonic tics that wax and wane in frequency but have persisted for >1 yr since first tic onset.

Persistent Tic Disorder is differentiated from Tourette Disorder in PTD it is limited to either motor or vocal tics (not both), whereas TD has both motor and vocal tics at some point in the illness (although not necessarily concurrently).

The tic disorders are hierarchical in order (i.e., TD followed by PTD followed by provisional tic disorder), such that once a tic disorder at one level of the hierarchy is diagnosed, a lower-hierarchy diagnosis cannot be made.

Generally, they may be an outlet for the suppressed anger and wearisomeness following control of aggression by the parents or the teacher.

Tics are commonly present in childhood at around 5 years of age, with male preponderance with the ratio of 3:1 in male to female ratio.

DEFINITION
Tics are sudden, brief non-rhythmic, rapid, repetitive, involuntary movements/ jerks/posture/activity of various body parts or production that maybe motor or vocal or both. They are often associated with a premonitory feeling that is relieved by performing the tic. Tics are mainly aggravated by excitement and stress and are quite often seen during wakefulness and disappear during sleep.

Types of TICS

There are two types of tics which is mainly seen. These include:

1. Motor tics
   1. Simple motor tics
   2. Complex motor tics
2. Vocal tics.
   1. Simple vocal tics
   2. Complex vocal tics.

MOTOR TICS
Motor tics are characterized by motor phenomena and it mostly have its involvement on the face, neck and shoulders. It is classified into two types; simple motor tics and complex motor tics.

SIMPLE MOTOR TICS: consist of sudden brief, meaningless movements such as grimacing, blinking, head jerking, shoulder shrugs and jerks involving the arm or leg.

COMPLEX MOTOR TICS: seem more purposeful, being characterized by activity such as chewing, jumping, hopping, tapping, on or smelling objects or self.

VOCAL TICS

The vocal tics are characterized by production of a sound, which can be either simple or complex vocal tics based on the simplicity of the sound.

SIMPLE VOCAL TICS: include throat clearing, coughing, sighing, tongue clicking, chirping, barking and grunting.

COMPLEX VOCAL TICS: include uttering words or profanities (coprolalia), burping, hiccup, repetitive utterances of words (echolalia, repeating other person’s words and palilalia, repeating later portions of own words).

EPIDEMIOLOGY

Prevalence rates for all tics range from 6–18% for boys and 3–11% for girls, with the rate of TD alone estimated as 0.8%. In general, PTD/TD has a male preponderance with a gender ratio varying from 2:1 to 4:1.

In a population-based study from India, the prevalence rate was estimated 35.34 per 100,000 [males: 56.19,95% CI 18.21- 131.15; females: 12.37, 95% CI 0.37- 68.93].

CLINICAL COURSE

• Onset of tics is typically between ages 4 and 6 years.
• The frequency of tics tends to wax and wane with peak tic severity between ages 10 and 12 years.
• Marked attenuation of tic severity in most individuals (65%) by age 18-20 years.
• A small percentage will have worsening tics into adulthood.
• New onset of tics in adulthood is very rare and most often is associated with exposure to drugs or insults to the central nervous system.
• Tics manifest similarly in all age-groups and changes in affected muscle groups and vocalizations occur over time.
• Some individuals may have tic-free periods of weeks to months.

According to DSM-5 Diagnostic Criteria for Tic Disorders, the criteria for each disorder are given below:

TOURETTE DISORDER

1. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently.
2. The tics may wax and wane in frequency but have persisted for >1 yr since first tic onset.
3. Onset is before age 18 yr.
4. The disturbance is not attributable to the physiologic effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington disease, postviral encephalitis).

PERSISTENT (CHRONIC) MOTOR OR VOCAL TIC DISORDER

1. Single or multiple motor or vocal tics have been present during the illness, but not both motor and vocal.
2. The tics may wax and wane in frequency but have persisted for >1 yr since first tic onset. C. Onset is before age 18 yr.
3. The disturbance is not attributable to the physiologic effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington disease, postviral encephalitis).
4. Criteria have never been met for Tourette disorder. Specify if: With motor tics only With vocal tics only

PROVISIONAL TIC DISORDER

1. Single or multiple motor and/or vocal tics.
2. The tics have been present for 1 yr since first tic onset.
3. Onset is before age 18 yr.
4. The disturbance is not attributable to the physiologic effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington disease, postviral encephalitis).
5. Criteria have never been met for Tourette disorder or persistent (chronic) motor or vocal tic disorder.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis includes the repetitive movements of childhood. Tics may be difficult to differentiate from stereotypies.

Although stereotypies are closely running with tics, stereotypies are typically rhythmic movements and do not demonstrate the change in body location or movement type over time that is typical of tics.

Compulsions may be difficult to differentiate from tics when tics have premonitory urges.

Tics may present in various neurologic illnesses (e.g., Wilson disease, neuroacanthocytosis, Huntington syndrome, various frontal-subcortical brain lesions), but it is rare for tics to be the only manifestation of these disorders.

MANAGEMENT OF TIC DISORDERS BY HOMEOPATHIC REMEDIES

AGARICUS MUSCARIS

• Begins with paroxysm of yawning.
• Twitching of lids and eyeballs.
• Quivering lids.
• Chorea amel. during sleep.
• Facial muscles feel stiff and twitching of the face.
• Strongly indicated for jerking twitching, trembling and itching.
• Painful twitching then the parts become stiff and cold.

CUPRUM MET

• Tearing twitching in arms and hands.
• Twitches in toes
• Spasmodic affections, cramps, convulsions beginning in toes and fingers
• Quick rolling of eyeballs with closed eyes.
• Constant protrusion and retraction of the tongue like a snake.
• Hiccough preceding the spasms.
• Jerking and twitching of muscles.

HYOSCYAMUS NIGER

• Low muttering speech, constant carphologia.
• Muscular twitching, spasmodic affections generally with delirium.
• Head is shaken toward and froward.
• Spasmodic closing of eyelids.
• Great restlessness; every muscle twitches.
• Confused babbling and prattling or much chattering, scolding and quarrelling.

ZINC METALLICUM

• Child repeats everything said to it.
• Rolls head from side to side.
• Automatic motion of head and hands.
• Rolling of eyes.
• Trembling and twitching of various muscle. Feet in continuous motion cannot keep still.
• Body jerks; nervous motion of feet when asleep.
• Loud screaming out at night in sleep without being aware.
• Violent, tremulous jerking of entire body in the evening.

ARGENTUM NITRICUM

• Trembling in affected parts.
• Unable to keep eyes fixed steadily.
• Walks and stands unsteadily, especially when unobserved
• Incoherent ideas and in-coordinated movements.

VERATRUM ALBUM

• Frenzy of excitement; shrieks, curses; howling all night.
• Howling and lamenting in a hoarse voice.
• Trembling of upper eyelid.

CONCLUSIONS
Tics in children are involuntary movements or sounds that can significantly affect a child’s life. Understanding the causes, types, and management strategies for tics is crucial in providing appropriate support and care for affected children. Genetic predisposition and abnormalities in brain circuits are believed to contribute to tic disorders. Effective management involves a combination of behavioural interventions and, in severe cases, medication. By offering understanding, support, and appropriate interventions, we can help children with tics thrive and lead fulfilling lives.

REFERENCES

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Dr. Edalissa Kharraswai
MD Scholar, Department of Paediatrics,
Father Muller Homoeopathic Medical College and Hospital