What you

need to know
about Motor
and Tic
Disorders
Presented by
Maryam Bibi
Roll No; 07
ADCP (M)
 • Motor disorders are malfunctions of the nervous system
that cause involuntary or uncontrollable movements or
actions of the body. These disorders can cause lack of
Neuro- intended movement or an excess of involuntary
developmental movement.
• The DSM-5 TR motor disorders include
Motor • Developmental coordination disorder
Disorders • Stereotypic movement disorder
• Tic disorders
Tourette’s Disorder
Persistent (chronic) motor or vocal tic disorder
Provisional tic disorder.
What is Developmental
coordination disorder?
?
 characterized by deficits in the acquisition and
execution of coordinated motor skills and is
manifested by clumsiness and slowness or
inaccuracy of performance of motor skills that
cause interference with activities of daily
living

How is
DCD
defined? Affecting fine and/or gross motor
coordination, in children and adults. While DCD
is often regarded as an umbrella term to cover
motor coordination difficulties
 DSM 5-TR Criteria
A. The acquisition and execution of coordinated motor skills is
substantially below that expected given the individual’s chronological
age and opportunity for skill learning and use. Difficulties are
manifested as clumsiness (e.g., dropping or bumping into objects) as
well as slowness and inaccuracy of performance of motor skills (e.g.,
catching an object, using scissors or cutlery, handwriting, riding a bike,
or participating in sports).
B. The motor skills deficit in Criterion A significantly and persistently
interferes with activities of daily living appropriate to chronological age
(e.g., self-care and self-maintenance) and impacts academic/school
productivity, prevocational and vocational activities, leisure, and play.
 DSM 5-TR Criteria
C. Onset of symptoms is in the early developmental period.
(typically not diagnosed before age 5 years)
D. The motor skills deficits are not better explained by
intellectual developmental disorder (intellectual disability) or
visual impairment and are not attributable to a neurological
condition affecting movement (e.g., cerebral palsy, muscular
dystrophy, degenerative disorder).
 • Is late in reaching milestones e.g. rolling over, sitting,
standing, walking, and speaking
• May not be able to run, hop, jump, or catch or kick a
ball although their peers can do so
• Has difficulty in walking up and down stairs
• Poor at dressing
• Slow, less precise and hesitant in most actions
The pre- • Appears not to be able to learn anything instinctively
school child but must be taught skills
• Falls over frequently
• Poor pencil grip
• Cannot do shape sorting games
• Artwork is very immature
• Often anxious and easily distracted
 DIFFICULTIES in;
• assembling puzzles, building models, playing
ball games
• handwriting, typing, driving, or carrying out
self-care skills.
The school • getting dressed, eating meals with age-
appropriate utensils and without mess
age child • engaging in physical games with others
• using specific tools in class such as rulers and
scissors
• participating in team exercise activities at
school.
 • Poor balance. Difficulty in riding a bicycle, going up
and down hills
• Poor posture and fatigue. Difficulty in standing for a
long time as a result of weak muscle tone. Floppy,
unstable round the joints.
• Poor integration of the two sides of the body.
• Difficulty with some sports involving jumping and
Gross motor cycling
co-ordination • Difficulty with team sports especially those which
involve catching a ball and batting.
skills • Difficulties with driving a car
• Lack of rhythm when dancing, doing aerobics
• Clumsy gait and movement.
• Difficulty changing direction, stopping and starting
actions
• Tendency to fall, trip, bump into things and people
 • Poor at two-handed tasks, causing problems
with using cutlery, cleaning, cooking, ironing,
craft work, playing musical instruments
• Poor manipulative skills. Difficulty with typing,
handwriting and drawing. May have a poor pen
Fine motor grip, press too hard when writing and have
difficulty when writing along a line
co-ordination • Inadequate grasp. Difficulty using tools and
domestic implements, locks and keys
skills • Difficulty with dressing and grooming activities,
such as doing hair, fastening clothes and tying
shoelaces
 Functional Consequences of DCD

Consequences of DCD include;

• Reduced participation in team play and sports
• Poor self-esteem and sense of self-worth
• Emotional or behavioral problems (stressed, depressed and anxious
easily). (Outbursts, compulsions and addictive behaviour)
• Impaired academic achievement
• Poor physical fitness
• Reduced physical activity and obesity
• Poor health-related quality of life.
 Development and Course
Onset is in early childhood. Delayed motor milestones may be the
first signs, or when the child attempts tasks such as holding a knife
or fork, buttoning clothes, playing ball games.

middle childhood; assembling puzzles, building models, playing

ball, and handwriting, organizing belongings, when motor
sequencing and coordination are required

early adulthood, difficulty in learning new tasks driving and using

tools. Inability to take notes and handwrite quickly may affect
performance in the workplace
 Risk and Prognostic Factors
Environmental
Genetic and physiological
• Prematurity and low birth
• Impairments in underlying
Weight
neurodevelopmental processes;
• Prenatal exposure to alcohol.
visual-motor skills, including both
visual-motor perception and
spatial mentalizing.
• Cerebellar dysfunction, which
affects the ability to make rapid
motoric adjustments as the
complexity of the required
movements increases, may also
be involved
• Precise neural basis is unclear
 Differential Diagnosis
ADHD
Individuals with ADHD may fall, bump into objects,
Motor impairments due to another medical
or
condition
knock things over. Careful observation across
Visual function impairment and specific
different contexts is required to ascertain if lack of
neurological disorders (e.g., cerebral palsy,
motor competence is attributable to distractibility
progressive lesions of the cerebellum,
and impulsiveness rather than to DCD
neuromuscular disorders). additional findings on
BOTH
neurological examination.
Autism spectrum disorder
Intellectual developmental disorder
uninterested in participating in tasks requiring
motor competences may be impaired in ID
complex coordination skills, such as ball sports,
if the motor difficulties are in excess of what
which will affect
could be accounted for by the ID, and criteria for
test performance and function but not reflect core
DOD are met,
motor competence.
BOTH
Co-occurrence is common.
BOTH
 Sspecific learning disorder

ADHD

ASD

Joint hypermobility syndrome

Comorbidity
communication disorders

severe reading disorders

How is DCD
assessed?
Clinical Assessment of children with
DCD
school or Past
Family and physical
workplace medical
developmental examination report history
history
DCD info Questionnaires
Motor testing
sheet
 • Movement Assessment Battery for Children,
2nd edition (MABC-2)
Assessment • Bruininks-Oseretsky Test of Motor Proficiency,
2nd Edition (BOT-2)
• Developmental Coordination Disorder
Cont Questionnaire (DCDQ’07)
• Movement Assessment Battery for Children
Checklist, 2nd ed. (MABC-2 Checklist)
• Parent interview and/or tools such as the
Listening for DCD Checklist
• Checklist for How to Recognise a Child with
• DCD
What is stereotypic movement
disorder?
 An individual has repetitive, seemingly driven, and
apparently purposeless motor behaviors, such as
hand flapping, body rocking, head banging, self-
biting, or hitting

How is
SMD
defined? The movements interfere with social, academic,
or other activities. If the behaviors cause self-
injury, this should be specified as part of the
diagnostic description
 DSM 5-TR Criteria
A. Repetitive, seemingly driven, and apparently purposeless motor
behavior (e.g., hand shaking or waving, body rocking, head banging,
self-biting, hitting own body).
B. The repetitive motor behavior interferes with social, academic,
or other activities and may result in self-injury.
C. Onset is in the early developmental period.
D. The repetitive motor behavior is not attributable to the
physiological effects of a substance or neurological condition and is
not better explained by another neurodevelopmental or mental
disorder (e.g., trichotillomania [hair-pulling disorder], obsessive-
compulsive disorder).
 DSM 5-TR Criteria
Specify if:
• Associated with a known genetic or other medical condition,
neurodevelopmental disorder, or environmental factor (e.g., Lesch-Nyhan
syndrome, intellectual developmental disorder [intellectual disability], intrauterine
alcohol exposure)
Coding note: Use additional code to identify the associated genetic or other
medical condition, neurodevelopmental disorder, or environmental factor.
Specify current severity:
• Mild: Symptoms are easily suppressed by sensory stimulus or distraction.
• Moderate: Symptoms require explicit protective measures and behavioral
• modification.
• Severe: Continuous monitoring and protective measures are required to prevent serious injury.
 Include
• Body rocking
• Bilateral flapping
non-self- • Rotating hand movements
injurious • Flicking or fluttering fingers in front
of the face
stereotypic • Arm waving or flapping

movements • Head nodding

• Mouth stretching is commonly seen
in association with upper limb
movements.
 include
• Repetitive head banging
• Face slapping
• Eye poking,
• Biting of hands, lips, or other body parts
Stereotyped • Eye poking is particularly concerning; it occurs
more frequently among children with visual
self- impairment.
injurious • Multiple movements may be combined
o Cocking the head
behaviors o Rocking the torso
o Waving a small string repetitively in front
of the face
 • sitting on hands
self- • wrapping arms in clothing
• finding a protective device
restraining
behaviors
 Development and Course
Begin within the first 3 years of life
Common in infancy and may be involved in acquisition of
motor mastery
Who develop complex motor stereotypies, approximately
• 80% exhibit symptoms before age 24 months
• 12% between 24 and 35 months
• 8% at 36 months or older
 Risk and Prognostic Factors
Environmental Genetic and physiological
• Social isolation • family history of motor
• Environmental stress stereotypies
• Fear may alter • reduction in the putamen
physiological state, volume in children with
resulting in increased stereotypies suggests that
frequency of distinct cortical-striatal
stereotypic behaviors. pathways associated with
habitual behaviors
• painful medical condition(e.g.,
middle ear infection, dental
problems, gastroesophageal
reflux).
 Differential Diagnosis
Normal development Tic disorders
common in infancy and early childhood Stereotypies may involve arms, hands, or the entire
Rocking may occur in the transition from sleep to body, while tics commonly involve eyes, face, head,
awake and shoulders. Stereotypies are more fixed,
Complex stereotypies are less common in typically rhythmic, and prolonged in duration than tics,
developing children and can usually be which, generally, are brief, rapid, random, and
suppressed by distraction or sensory stimulation fluctuating.
daily routine is rarely affected Stereotypies are ego-syntonic as opposed to tics,
Obsessive-compulsive and related disorders which are usually ego-dystonic
absence of obsessions, as well as by the nature of the Autism spectrum disorder
repetitive behaviors. Stereotypic movements may be a presenting
OCD the individual feels driven to perform repetitive symptom of ASD. Deficits of social communication
behaviors in response to an obsession and reciprocity manifesting in ASD are generally
Trichotillomania and excoriation disorder are body- absent in SMD
focused repetitive behaviors. Seemingly driven but social interaction, social communication, and rigid
not apparently purposeless, not patterned or repetitive behaviors and interests
rhythmical. Not in developmental period BOTH when self-injury or behaviour is severe
 Motor coordination disorder

ADHD

Tics/ Tourette’s disorder

Comorbidity
Anxiety

communication disorders

severe reading disorders

How is SMD
assessed?
Clinical Assessment of children with
SMD
environmental Past
Family and physical
factor medical
developmental examination history
history
complete
stereotyped stereotypy
behavior severity
scale
scale
What are
tics?
 A sudden, rapid recurrent and non
rhythmic motor movement or
vocalization

How is a
tic
defined? Premonitory urge: sensory phenomena (itch,
tingle, vague discomfort) that precede and
trigger the urge to tic
Natural course: waxing and waning symptoms.
Rarely occur during sleep
 DSM 5 TR Criteria
Tourette’s Disorder
A. Both multiple motor and one or more vocal tics have been
present at some time during the illness, although not necessarily
concurrently.
B. The tics may wax and wane in frequency but have persisted
for more than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological
effects of a substance (e.g., cocaine) or another medical
condition (e.g., Huntington’s disease, postviral encephalitis).
 DSM 5 TR Criteria
Persistent (Chronic) Motor or Vocal Tic Disorder
A. Single or multiple motor or vocal tics have been present during the
illness, but not both motor and vocal.
B. more than 1 year
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a
substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease,
postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder.
Specify if:
With motor tics only
 DSM 5 TR Criteria
Persistent (Chronic) Motor or Vocal Tic Disorder
A. Single or multiple motor or vocal tics have been present during the
illness, but not both motor and vocal.
B. more than 1 year
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a
substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease,
postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder.
Specify if:
With motor tics only
 DSM 5 TR Criteria
Provisional Tic Disorder
A. Single or multiple motor and/or vocal tics.
B. Less than 1 year
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological
effects of a substance (e.g., cocaine) or another medical
condition (e.g., Huntington’s disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder or
persistent (chronic) motor or vocal tic disorder.
 • Sudden, fast, brief, meaningless
movements, involving 1-2 muscle
groups
• Eye blinking
Simple • Eye movements
• Grimacing
Motor • Nose twitching
Tics • Mouth movements
• Head jerks
• Shoulder shrugs
• Abdominal tensing
• facial grimaces
 • Sudden, meaningless sounds or noises
• Throat clearing
• Coughing
Simple • Sniffing

Vocal • Screeching
• Barking
Tics • Grunting
 Touching objects or self
Slower, longer, more
“purposeful” movements
Gestures with hands
Complex Rarely seen in absence
Motor of simple motor tics
Holding and twisting
Tics Limbs, jumping

Obscene gestures
 Complex Vocal
Tics
Syllables, words, phrases or statements

Odd patterns of speech

Repetition of another person’s spoken words

Obscene, inappropriate and aggressive words or statements

 Many children
Peak tic severity
experience an
occurs between the
improvement in
age of 10 and 12
adolescence

Tic
Severity Tic severity is
measured using a
Tic severity might
indicate impairment
and therefore
treatment. The goal
scale
of treatment is to
reduce tic severity
 Risk and Prognostic Factors
Environmental Genetic and physiological
• Advanced paternal age • heritability estimated to be
• Pre- and perinatal adverse 70%–85%
events • Risk alleles for Tourette’s
• Impaired fetal growth disorder and rare genetic
• Maternal intra-partum variants in families
fever • Chronic tic disorders have
• Maternal smoking shared genetic variance with
• Severe maternal OCD, ADHD
psychosocial stress • increased risk to develop an
• Cesarean delivery. autoimmune disorder (e.g.,
Hashimoto’s thyroiditis).
 Differential Diagnosis

Paroxysmal dyskinesias.
Stereotypies episodic involuntary
Rhythmic, no change over time, no premonitory dystonic movements that are precipitated by
urge voluntary movement or exertion
self-soothing or and less commonly arise from normal background
pleasurable and stop with distraction activity
former’s earlier age at onset (often younger than 3 Obsessive-compulsive and related disorders
years), prolonged duration (seconds to compulsions of OCD are aimed at preventing or
minutes), reducing anxiety or distress and are usually
lacking a premonitory sensation performed in response to an obsession
cessation with distraction (e.g., hearing name called feel the need to perform the action in a particular
or being touched) fashion, equally on both
sides of the body a certain number of times or until
a “just right” feeling is achieved.
Comorbidity
of tic Psychiatric comorbidities include:
disorders • ADHD – 54%
• OCD – 50%
• Anxiety disorders 36%
• Disruptive Behaviour Disorders 30%
• Eating disorders 2%
• Psychotic disorders 1%
• Substance use 6%
Quality of • Quality of life is impacted more by comorbidity than tic severity

Life • In children, the severity of ADHD has greatest impact

• In adults, anxiety and depression have greatest impact
• Improving quality of life is paramount in treatment of tics
How are
tics
assessed?
Clinical Assessment of People with
Tics
Developmental Past
Family history Medication use
history medical
history

Neurological Assessment of tic

History of tics
exam severity by Yale
Global Tic
Severity Scale
 Imperative to screen for
comorbidities

Other psychiatric
ADHD OCD
conditions

In people with tics clinicians assess for OCD, ADHD and other
psychiatric conditions to ensure appropriate treatment is provided
for the different conditions.
Disorders
commonly Females more likely to have depression,
occurring anxiety and eating disorders
with Males more likely to have ADHD and
Tourettes disruptive behaviour disorders
Adults and more likely to have OCD, mood,
Adolescents anxiety, eating and substance use
disorders
Children more likely to have ADHD
Tic disorder
https://www.youtube.com/watch?v=1SEKZLivG54&list=LL&index=1
https://www.youtube.com/watch?v=S3jqvXsYg0U&list=LL&index=2
https://www.youtube.com/watch?v=CFaiN_nZsYk&list=LL&index=4
Developmental coordination disorder
https://www.youtube.com/watch?v=jDXDXDoUqzc&list=LL&index=6
https://www.youtube.com/watch?v=NW_keJoXlRo&list=LL&index=7
https://www.youtube.com/watch?v=C8_Uey5VtX0&list=LL&index=8
Stereotypic movement disorder
https://www.youtube.com/watch?v=nvkCpOBtn2M
https://www.youtube.com/watch?v=fw5B2wxrYAc
https://www.youtube.com/watch?v=gJVE8r51ktA
https://www.youtube.com/watch?v=M8ddNY3FCOY
 References
• .
Murphy, Tanya K. et al. Journal of the American Academy of Child & Adolescent Psychiatry , Volume 52 ,
Issue 12
, 1341 - 1359
• Bestha, et al. Management of tics and Tourette’s disorder: an update. Expert Opin. Pharmacother. (2010)
11(11).
• Treatment of ADHD in children with tics: A randomized controlled trial (TACT). Neurology. 2002.
Feb 26;58(4):527-36.
• Clinical evaluation of Youth with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Recommendations from the
PANS 2013 PANS Consortium Conference
Chang Kiki, Frankovich Jennifer, Cooperstock Michael, Cunningham Madeleine W., Latimer M. Elizabeth, Murphy Tanya
K., Pasternack Mark, Thienemann Margo, Williams Kyle, Walter Jolan, Swedo Susan E., and From the PANS Collaborative
Consortium. Journal of Child and Adolescent Psychopharmacology. February 2015, 25(1): 3-13. doi:10.1089/cap.2014.0084.