Tics and Problem Behaviors in Schoolchildren: Prevalence,

Characterization, and Associations

Lisa A. Snider, MD; Laura D. Seligman, PhD; Bethany R. Ketchen, BA; Sara J. Levitt; Lauren R. Bates;
Marjorie A. Garvey, MD; and Susan E. Swedo, MD

ABSTRACT. Objective. Tic disorders are the most (clinic-based vs community sample). A reporting
common movement disorder diagnosed in children and bias could explain why lower rates of tic frequency
have symptoms that fluctuate in frequency and intensity are found in studies based on parental report when
over time. We conducted an 8-month longitudinal obser- compared with those using direct observation. Be-
vational study to determine the variations in frequency
cause clinic-based studies include mainly children
of motor tics and associated problem behaviors.
Methods. A total of 553 children, kindergarten with severe tic symptoms, ascertainment bias could
through sixth grade, were observed monthly from No- explain why these studies tend to underestimate the
vember 1999 to June 2000 by 3 raters. Motor tics were prevalence of tics when compared with community-
recorded by location and rated for severity as none (0), based studies. Although there is a limited amount of
mild (1), moderate (2), or severe (3). Problem behaviors research on the incidence of transient tic behaviors,
were rated as absent (0), subclinical (1), or clinical (2) in community-based reports suggest that children are 5
each of 6 categories: disruptive, hyperactive, impulsive, to 12 times more likely to be identified as having a tic
aggressive, anxious, and distracted. disorder than adults, and that boys are more com-
Results. The monthly point prevalence of motor tics
ranged from 3.2% to 9.6%, with an overall frequency of
monly affected than girls.3,4 The ratio of boys to girls
24.4%. The monthly point prevalence of problem behav- affected with a tic disorder is ⬍2 to 1 in the majority
iors ranged from 2.6% to 11.0%, with an overall frequency of community samples5 but has been reported as
of 25.7%. The incidence of motor tics and problem be- high as 9 to 1 in clinic-based samples.3,6
haviors was significantly higher during the winter The transient nature of tic symptoms may also
months of November through February, compared with contribute to the large variability in the cross-sec-
the spring months of March through June (motor tics: z ⴝ tional estimate of tic prevalence. There is a fluctua-
4.97; problem behaviors: z ⴝ 3.79). Motor tics were ob- tion in tic frequency and intensity over time.7 A child
served in 2 distinct patterns (isolated and persistent),
may have 3 weeks of debilitating motor tics and then
which varied by the number of months present, gender
ratio of affected children, severity of tic symptoms, and 3 months of relative quiescence. The severity of a tic
association with problem behaviors. is determined by its frequency, intensity, and com-
Conclusions. Motor tics and problem behaviors are plexity. However, the diagnosis of a tic disorder is
frequent occurrences among schoolchildren and seem to dependent not on the severity but on the duration of
occur more frequently during the winter months. For the symptoms.8 As such, a child with a mild eye tic
most children, the tics were mild, observed on only 1 occurring a few times a month over a 1-year period
occasion, and were not accompanied by problem would be classified as having a chronic motor tic
behaviors. Pediatrics 2002;110:331–336; observational disorder, while a child with a continuous debilitating
study, longitudinal study, tic disorder, childhood onset.
tic present for less than a year would be diagnosed
with a transient tic disorder. The breadth of the tic

T
ic disorders are the most common movement spectrum not only makes accurate diagnosis and
disorder diagnosed in children,1 with 5% to characterization challenging, but also causes diffi-
20% of schoolchildren experiencing a simple or culty in determining the best treatment course for a
complex motor or vocal tic during their lifetime.2 child who presents with recent onset tic symptoms.9
This great variation in estimated prevalence could be Children diagnosed with a tic disorder are often
partially explained by differences in the methods found to have accompanying behavioral difficulties,
used by individual investigators (parental report vs
including disinhibited speech or conduct, impulsiv-
observation) and the different populations studied
ity, distractibility, motoric hyperactivity, and obses-
sive-compulsive symptoms.5 These behavior symp-
From the Pediatrics and Developmental Neuropsychiatry Branch, National toms are often more impairing than the tics and
Institute of Mental Health, National Institutes of Health, Bethesda, Mary- frequently are the reason that treatment is sought for
land.
Dr Seligman is currently at the Department of Psychology, University of
the child. To date, however, there have been no
Toledo, Toledo, Ohio. longitudinal investigations of the association be-
Received for publication Oct 22, 2001; accepted Feb 8, 2002. tween tic symptoms and problem behaviors among
Reprint requests to (L.A.S.) Pediatrics and Developmental Neuropsychiatry schoolchildren.
Branch, 10 Center Dr, Room 4N208, MSC 1255, Bethesda, MD 20892-1255.
E-mail: [email protected]
The purpose of this study was to determine the
PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad- prevalence of tics and problem behaviors by monthly
emy of Pediatrics. systematic observations in a large community sam-

PEDIATRICS Vol. 110 No. 2 August 2002 331

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ple of kindergarten through sixth-grade children. We facial grimaces) in repetitive patterns. At the initiation of the
hypothesized that the longitudinal collection of ob- study, parents were asked to complete a checklist of problem
behaviors and tic symptoms (like shoulder shrugs, eye blinks ,and
servational data would provide a better estimate of facial grimaces) that were present in their child. They also pro-
frequency in symptoms that vary over time, as well vided a listing of any psychiatric diagnoses or medications pre-
as allow an examination of the seasonal variation in scribed for their child.
incidence.
Data Analysis
METHODS Point-prevalence rates at each point of data collection, as well
Participants as an overall 8-month frequency, were determined by simple
frequency counts. This was done separately for tics and behavioral
The participants of this investigation were 553 kindergarten symptoms. A McNemar’s ␹2 analysis was used to examine the
through sixth-grade children enrolled at a large elementary school association between tics and observed behavior symptoms. A
in an upper-middle class suburb of Washington, DC. The school is Yates ␹2 analysis was used to compare the isolated and persistent
notable for its racial and ethnic diversity. These 553 children came groups for observed behavior symptoms and gender ratio of
from 28 classrooms chosen on the basis of the teacher’s willingness affected children, as well as in the children observed to have
to have his or her class participate. Of the 553 participating chil- motor tics and those that did not for behaviors observed by the
dren, 50.4% (279/553) were boys and 49.5% (274/553) were girls. teachers. A repeated measures analysis of variance was performed
The study was discussed at 2 parent-teacher meetings and in to compare the mean severity of the motor tics by group with
the school’s newsletter before a letter of invitation and consent mean tic severity rating as the dependent variable and pattern of
forms being sent to the children’s homes for consideration. Writ- tic symptoms as the between-subjects variable. An exact binomial
ten consent from a parent/guardian and written assent from the calculation was performed to compare the incidence during the
child were requested. If either the child or parent declined partic- months of November through February with the incidence during
ipation in the study, no data were collected on that child. Further- the months of March through June for both motor tics and prob-
more, if either the parent or child objected to the observations lem behaviors independently. To avoid the bias of children with
being done on other children in the classroom while the child was multiple months of observed motor tics or problem behaviors, the
present, the observations were scheduled at a time when the child seasonal incidences were calculated from the children with motor
was not present in his or her classroom (n ⫽ 3) or the classroom tics in the isolated group (n ⫽ 101) and the children who had only
was not entered into the study (1 sixth-grade and 1 second-grade 1 month of problem behaviors observed (n ⫽ 106). The data were
classroom). The study was performed with the approval of the analyzed with the Number Cruncher Statistical Systems statistical
Institutional Review Board of the National Institute of Mental package,11 with significance set at the .05 level.
Health, Bethesda, Maryland.

Direct Observation RESULTS

The direct observation of tics and classroom behaviors were Motor tics were observed in 135 (24.4%) of the 553
done by 1 of 3 raters each month who was trained to reliability by participating children during at least 1 month of the
a pediatric neurologist (M.A.G.) and a psychologist (L.D.S.) expe- study. The monthly prevalence of motor tics ranged
rienced in rating classroom behaviors. Measures of interrater and
inter-interval reliability were obtained by having observers rate
from 3.2% to 9.6% (Fig 1). There was a significantly
classrooms in concert with 1 of the primary raters (M.A.G. and higher incidence of motor tics observed during the
L.D.S.) during selected months of the study period and a post- winter months of November through February (76/
study analysis of the individual raters observations. The observa- 101, 75%), compared with the spring months of
tions occurred monthly over 8 months from November 1999 to March through June (25/101, 25%; z ⫽ 4.97; P ⬍ .01;
June 2000. The raters were located at the front of the classroom
and were able to move about as needed to directly observe each Fig 2). Boys were observed to have a greater fre-
participant. Teachers provided classroom-seating charts to allow quency of motor tics than girls by a ratio of 2:1
the observations to be performed in a systematic manner. The (92:43). Motor tics observed by grade ranged from
classroom as a whole was observed for 5 minutes and then each 15% (16/109) in the sixth grade to 47% (27/57) in the
study participant was observed for 3 minutes noting the child’s
demeanor and the presence of tics. Motor tics were defined as 3 or
first grade (Table 1). Eye tics were the most common
more repetitions of the same movement or motion and were rated location for a motor tic to be observed, with 68%
as none (0), mild (1), moderate (2), or severe (3). The location of the (84/135) of the children with tics observed to have an
adventitious movements (eye, nose, mouth, head, neck, shoulders, eye tic. Mouth tics were seen in 47%, nose tics in 25%,
extremity, trunk, or other) was also noted. Vocal tics were not head/neck tics in 8%, shoulder tics in 3%, extremity
rated because of the level of background noise during the class-
room observations and the variable distances of the rater from the tics in 2%, trunk tics in 1%, and other tics in 10% of
child being observed. Problem behaviors were rated by direct the children observed to have motor tics. When look-
observation as absent (0), subclinical (1), or clinical (2) in each of 6 ing at the entire population, the children observed to
categories: disruptive, hyperactive, impulsive, aggressive, anx- have motor tics were not significantly more likely to
ious, and distracted.
have an observed problem behavior than children
Teacher Reports without motor tics. Children observed to have a
A 13-item teacher report form based on the Conners’ Teacher problem behavior were not significantly more likely
Rating Scale-Revised10 was completed by participating teachers. to have a motor tic than children without problem
Each teacher completed a single form for all of the students behaviors (␹2 ⫽ 0.31; P ⫽ .58).
participating in the study in his or her class each month. This form The children with motor tics clustered into 2
rated the following behaviors in each participant over the entire
month: impulsivity, inattention, irritability, emotional lability,
groups by duration of symptoms. Isolated motor tics,
anxiety/tension, disruptive behaviors, and decline in academic present for either 1 month or 2 consecutive months,
performance. When a symptom was present, the teacher gave a were observed in 101 (101/553, 18%) children and
rating of mild (1), moderate (2), or severe (3) and noted whether persistent motor tics, present for 2 nonconsecutive
the given behavior prompted intervention and what the specific months or ⬎3 months, were observed in 34 (34/553,
intervention was.
6.1%) children. The persistent group had a mean
Parental Report Form severity score of 1.25, which was significantly higher
Tics were explained to the parents at 2 parent-teacher meetings than the isolated group with a score of 1.08 (t ⫽ 2.7;
as abnormal movements (like shoulder shrugs, eye blinks, and P ⬍ .01). The persistent group had a significantly

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 Fig 1. Percentage of children observed each month to exhibit motor tics or problem behaviors.

higher ratio of boys to girls at 7.5:1, than the isolated haviors ranged from 2.6% to 11.0% (Fig 1). There was
group with a ratio of 1.6:1 (␹2 ⫽ 13.6; P ⬍ .01; Table a significantly higher incidence of problem behaviors
1). The occurrence of motor tics and problem behav- observed during the winter months of November
iors was found to be significantly associated in the through February (73/106, 69%) compared with the
persistent group but not in the isolated group. Of the spring months of March through June (33/106, 31%;
34 children with persistent tics, 14 (41%) were ob- z ⫽ 3.79; P ⬍ .01; Fig. 2). Of the 142 children who
served to have a problem behavior in the months were observed to have a problem behavior, 73%
they were observed to have tic symptoms, while in (103/142) were observed to have a distracted behav-
the isolated group only 23 (23%) of the 101 children ior at least once during the 8 months. Hyperactive
were observed to have a concurrent problem behav- behaviors were observed in 57 of the children (40%),
ior (␹2 ⫽ 7.3; P ⬍ .01). impulsive behaviors in 22 (15%), anxious behaviors
There appeared to be 2 subgroups within the cat- in 17 (12%), disruptive behaviors in 16 (11%), and
egory of persistent tics (n ⫽ 34), with 7 children aggressive behaviors in 7 (5%) during the study pe-
having motor tics for at least 4 of the months ob- riod. Problem behaviors were more common among
served (chronic group) and the other 27 children boys by a 2:1 ratio (96:46). Frequency of problem
having motor tics for 2 or 3 months but not consec- behaviors by grade ranged from 8% (9/109) in the
utively (episodic group). Although there were not sixth grade to 51% (29/57) in the first grade. Of the
significant differences between the groups, certain 553 participating children, only 36 (6.5%) had a prob-
tendencies were noted. The mean severity of the tics lem behavior observed for ⬎1 month, with only 14
observed in the chronic group was higher than the (2.5%) having problem behaviors present for 3 or
episodic group (1.45 vs 1.19, respectively.) Only 1 greater months. Problem behaviors that persisted for
(14%) of the 7 children in the chronic group had a ⬎1 month were more common among the kindergar-
concurrent observed problem behavior, whereas 13 ten, first-, and second-grade participants by a 2:1
(48%) of the 27 children in the episodic group were ratio (25:11), and more common among boys at a
observed to have concurrent problem behaviors. The ratio of 3.5:1 (28:8; Table 2).
ratio of boys to girls in the affected children was not Teacher-reported behaviors were collected for 361
different between the 2 groups (6:1 in the chronic of the children over a 5-month period (January
group and 8:1 in the episodic group). through May). The teachers reported 67% (242/361)
Problem behaviors were observed in 142 (25.7%) of of the children to have a problem behavior for at
the 553 participating children in 1 or more of the 6 least 1 month. The monthly prevalence did not vary
behavior categories during at least 1 month of the significantly, ranging from 41% (149/361) to 51%
study. The monthly point prevalence of problem be- (183/361). Of the 361 children who were rated by

ARTICLES 333
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 Fig 2. Point prevalence of new cases each month of motor tics or problem behaviors.

TABLE 1. Tic Characteristics Observed in Schoolchildren TABLE 2. Problem Behaviors Observed in Schoolchildren
No Tics Isolated Tics Persistent Tics No Problem Any Problem Behavior
Behaviors Behavior(s) Persisting
N ⫽ 553 418 (76%) 101 (18%) 34 (6.1%) ⬎1 Month
Boys (n ⫽ 279) 187 (67%) 62 (22%) 30 (11%) N ⫽ 553 411 (74%) 142 (26%) 36 (6.5%)
Girls (n ⫽ 274) 231 (84%) 39 (14%) 4 (1.5%)
Boys (n ⫽ 279) 183 (66%) 96 (34%) 28 (10%)
K (n ⫽ 83) 66 (80%) 9 (11%) 8 (9.6%) Girls (n ⫽ 274) 228 (83%) 46 (17%) 8 (2.9%)
First (n ⫽ 57) 30 (53%) 22 (38%) 5 (8.8%)
Second (n ⫽ 85) 69 (81%) 13 (15%) 3 (3.5%) K (n ⫽ 83) 62 (75%) 21 (25%) 8 (10%)
Third (n ⫽ 43) 34 (79%) 5 (12%) 4 (9.3%) First (n ⫽ 57) 28 (49%) 29 (51%) 11 (19%)
Fourth (n ⫽ 98) 69 (71%) 20 (20%) 9 (9.2%) Second (n ⫽ 85) 62 (73%) 23 (27%) 6 (7.1%)
Fifth (n ⫽ 78) 57 (73%) 18 (23%) 3 (3.8%) Third (n ⫽ 43) 29 (67%) 14 (33%) 2 (4.7%)
Sixth (n ⫽ 109) 93 (85%) 14 (13%) 2 (1.8%) Fourth (n ⫽ 98) 69 (70%) 29 (30%) 4 (4.1%)
Fifth (n ⫽ 78) 61 (78%) 17 (22%) 4 (5.1%)
Sixth (n ⫽ 109) 100 (92%) 9 (8%) 1 (1.0%)
their teachers, 90 were observed to have motor tics.
The teachers reported problem behaviors in 66 (73%)
of these 90 children with motor tics. The teachers motor tics during the study, 3 were reported to have
reported significantly less problem behaviors in 90 only vocal tics and 3 others were receiving medica-
class- and sex-matched controls without motor tics, tions for their movement disorders. There were 2
with only 41 (46%) reported to have problem behav- children reported on the parental form to have the
iors (␹2 ⫽ 13.3; P ⬍ .01). diagnosis of Tourette syndrome. One child, who was
The parental report forms were returned for 27% reported to be on medication for his movement dis-
(152/553) of the children. Of 152 children who had order was not observed to have motor tics; the other
parental reports 33 (22%) were observed to have child was not reported to be on medication and
motor tics, whereas only 15 (10%) were reported by motor tics were observed during 4 months of the
their parents to have a diagnosis of motor tics, vocal study.
tics, or Tourette syndrome. Of the 15 children re-
ported to have a tic disorder, only 7 (21%) were DISCUSSION
observed to have motor tics during the 8 months of Our results suggest that the occurrence of motor
the study. Of the 8 children reported to have a tic tics and problem behaviors are common among ele-
disorder by their parent but not observed to have mentary schoolchildren, with approximately one

334 TICS AND PROBLEM BEHAVIORS IN SCHOOLCHILDREN

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quarter of all children exhibiting each of these symp- many clinic-based studies of tic disorders the ratio of
toms. Motor tics and problem behaviors were not boys to girls is 6 – 8:1 and in community-based stud-
present simultaneously, but appeared to occur inde- ies the ratio closer to 2:1. Our persistent group would
pendently. For most children, the symptoms were be more indicative of a clinic-based sample because
transient and observed during only 1 month of the of the fact that children with more severe and endur-
study. The incidence of tics and problem behaviors ing tics are more likely to be seen by a physician. Our
was found to be 3 times higher during the winter isolated group with relatively mild symptoms has a
months than the spring months. However, conclu- similar ratio to the community-based studies. It has
sions about seasonal prevalence are limited by the also been previously reported that boys exhibit
fact that the children were not observed from July higher rates of externalizing behaviors when com-
through October. pared with girls.16 These externalizing behaviors
The rate of motor tics observed in our study is could have been picked up by the raters more than
higher than previously reported. This may be the the internalizing behaviors, which would not be as
result of the of the methodology employed, which easily detected in a brief observation. Our finding
used longitudinal direct observations in a commu- that a disproportionate number of boys were ob-
nity sample. Observing the same population of chil- served to have problem behaviors when compared
dren on multiple occasions provided an opportunity with girls could be partially explained by this gender
to “catch” children when tics were present. In con- discrepancy in behavior types.
trast, a cross-sectional study during the month of Through the longitudinal collection of data, we
March would have estimated tic frequency at only were able to characterize 2 distinct patterns of tic
3.4%. Clinic-based studies are believed to underesti- symptoms: isolated motor tics which were present
mate the frequency of tics, as only a small fraction of for either 1 month or 2 consecutive months, and
children with tics are brought to a health care pro- persistent motor tics which were present for 2 non-
vider for evaluation.12 We also found evidence of a consecutive months or ⬎3 months. The children in
reporting bias in our study with ⬍50% of the chil- the isolated group (18%, 101/553) may be included
dren with observed tics reported to have tics by their in the Diagnostic and Statistical Manual of Mental Dis-
parents. Results of this investigation also support the orders, Fourth Edition, definition of transient tic dis-
previously reported findings that tics wax and wane order. The persistent group had a significantly
in severity and frequency over time,7 as individual higher mean severity rating for motor tics than the
children had fluctuating symptoms over the obser- isolated group. The children in the persistent group
vation period. were also 2 times more likely to exhibit nonfacial tics
Previous studies have reported that behavior than children in the isolated group. This suggests
problems are often comorbid with tic disorders.13 It that eye blinks and facial tics when seen alone are
is possible that clinic-based studies overestimate the more likely to be transient than tics located in other
frequency of comorbid behavior problems, in part areas of the body. However, additional study is re-
because the behavior problems can be more trouble- quired before such a conclusion can be reached as
some than the tic symptoms and become the moti- many of the children in the persistent group also had
vating factor for seeking treatment.14,15 It is also pos- facial tics.
sible that clinic-based studies estimate accurately the Seven of the 34 children in the persistent group
prevalence of comorbid conditions and that the dis- were observed to have motor tics for at least 4 of the
crepancy is from the inappropriate generalization of months in the study (a chronic group), and 27 par-
clinic based data to community populations. Our ticipants were observed to have motor tics for 2 or 3
data suggest that behavior comorbidity is associated months but not consecutively (an episodic group).
with the more persistent tic symptoms versus all tic The children in the chronic group (1.3%, 7/553) may
symptoms, as children with isolated tics lasting only represent children with a chronic tic disorder or
1 to 2 months did not have increased rates of prob- Tourette syndrome diagnosis. The children in the
lem behaviors, whereas those with a more persistent episodic group had more observed behaviors during
course did. the months they had tic symptoms than the partici-
The frequency of observed problem behaviors did pants in the chronic group or the isolated group.
not correlate well with that reported by the teachers. Although the children in the chronic group were
This may reflect a difference in the method of data rated by their teachers as having problem behaviors
collection between the raters and the teachers. The during most of the study months, they were not
teachers were rating the children on their behaviors found to exhibit these behaviors when observed to
over the entire month, whereas the observers rated have motor tics by our raters. It is possible that these
behaviors present during 1 brief time period each children had more internalizing problem behaviors
month. For the behaviors reported by the teachers, that were noted by teachers who observed them on a
there did not seem to be any temporal variation in daily basis that could not be picked up by the raters’
the frequency and the same children were repeatedly brief observation period.
noted to have behavior problems each month. The episodic group of children (4.8%, 27/553)
This study supports previous findings that the could fit into any of the Diagnostic and Statistical
prevalence of tics is more common among boys than Manual of Mental Disorders, Fourth Edition tic disorder
girls. For motor tics, the ratio of boys to girls was 1.6 diagnoses, or may represent a newly defined sub-
to 1 in the isolated group and 7.5 to 1 in the persistent group of patients whose tics are environmentally
group. This correlates well with the findings that in influenced. We found that new cases of motor tics

ARTICLES 335
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and problem behaviors were most common during Tourette’s syndrome and obsessive-compulsive disorder. Evidence sup-
porting a genetic relationship. Arch Gen Psychiatry. 1986;43:1180 –1182
the months of November through February, which
7. Saunders-Pullman R, Braun I, Bressman S. Pediatric movement disor-
would coincide with the previously reported sea- ders. Child Adolesc Psychiatry Clin North Am. 1999;8:747–765
sonal prevalence of streptococcal infections.17,18 Car- 8. American Psychiatric Association, American Psychiatric Association,
dona and colleagues19 reported that exposure to Task Force on DSM-IV. Diagnostic and Statistical Manual of Mental Dis-
streptococcal antigens was correlated with the onset orders DSM-IV-TR. 4th ed. Text revision ed. Washington, DC: American
Psychiatric Association; 2000
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9. Singer HS, Walkup JT. Tourette syndrome and other tic disorders.
Kiessling et al20 reported an association between a Diagnosis, pathophysiology, and treatment. Medicine. 1991;70:15–31
community outbreak of streptococcal infections in 10. Conners CK. Conners’ Teacher Rating Scale-Revised (Long Form).
Rhode Island and a 10-fold rise in the number of Tonawanda, NY: Multi-Health Systems; 1997
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clinic with new onset tics. Systems; 1999
12. Mason A, Banerjee S, Eapen V, Zeitlin H, Robertson MM. The preva-
The results of the present investigation demon- lence of Tourette syndrome in a mainstream school population. Dev
strate that motor tics are common among elementa- Med Child Neurol. 1998;405:292–296
ry-schoolchildren, but for most children are mild, 13. Bagheri MM, Kerbeshian J, Burd L. Recognition and management of
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PUBLIC RELATIONS TRUISM

“It’s not what you say, but how you say it, that matters.”

Ewen S. PR! A Social History of Spin. New York, NY: Basic Books; 1996

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 Tics and Problem Behaviors in Schoolchildren: Prevalence, Characterization,
and Associations
Lisa A. Snider, Laura D. Seligman, Bethany R. Ketchen, Sara J. Levitt, Lauren R.
Bates, Marjorie A. Garvey and Susan E. Swedo
Pediatrics 2002;110;331
DOI: 10.1542/peds.110.2.331

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2002 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
.

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Tics and Problem Behaviors in Schoolchildren: Prevalence, Characterization,
and Associations
Lisa A. Snider, Laura D. Seligman, Bethany R. Ketchen, Sara J. Levitt, Lauren R.
Bates, Marjorie A. Garvey and Susan E. Swedo
Pediatrics 2002;110;331
DOI: 10.1542/peds.110.2.331

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/110/2/331

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2002 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
.

Downloaded from http://pediatrics.aappublications.org/ by guest on February 25, 2018