Tics or Tourette Syndrome – Primary Care, Outpatient Specialty Care and Emergency Department

Differential Diagnosis

Seizures	Not suppressible Rapid eyelid flutters or a jerk of the same body part every time Family history of epilepsy Direct families to record video of movements and to determine if child is responsive during tic-like behavior
Functional Tic-Like Movement	Most common age of onset > 12 yrs old Abrupt, explosive onset Not suppressible May increase during physical exam Both tics and functional tic-like movements may increase during discussion of history
Stereotypies	Self-stimulatory behaviors, e.g., “stims” < 3 yrs of age at onset Rhythmic movement, usually involving arms Associated with positive emotions Can be easily suppressed, unlike tics
Infantile Gratification	Posturing during infant masturbation Adduction of the thighs, sitting on hand or foot and rhythmic pelvic movements
Shuddering Spells	Benign nonepileptic events Typically begins in infancy Brief (seconds-long) rapid shivering of the head, shoulders, and sometimes trunk Can occur up to > 100× per day Clinical Reasoning: Shuddering Attacks in Infancy
Sandifer Syndrome	Occurs with reflux Back arching
Tardive Dyskinesia	Medication-induced (neuroleptics or anti-emetics) hyperkinetic movement disorder Focus on orofacial movements Neurology or Psychiatry Abnormal Involuntary Movement Scale (AIMS)
Myoclonus	Quick, rapid jerks of any body part, twitches Not suppressible No premonitory urge
Chorea	Continuous random-appearing sequence of involuntary movements Dance-like movements No premonitory urge
Dystonia	Involuntary movements characterized by sustained muscle contractions Abnormal and repetitive movements or postures No premonitory urge
Medication/Substance Withdrawal	Caffeine or benzodiazepines are common agents

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Tics or Tourette Syndrome – Primary Care, Outpatient Specialty Care and Emergency Department

Differential Diagnosis

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Tics or Tourette Syndrome – Primary Care, Outpatient Specialty Care and Emergency Department – Differential Diagnosis

Tics or Tourette Syndrome – Primary Care, Outpatient Specialty Care and Emergency Department

Differential Diagnosis