Snapshot An 9-year-old boy is brought by his parents to the pediatrician due to concerns about his behavior in the past year. His teacher has complained in several parent-teacher conferences that their child has frequently disrupted quiet reading hours with episodes of grunting and getting out of his seat to jump. The parents note that these behaviors are similar to what they have observed at home as well. The boy had a period of 2 months where he did not show any of these behaviors, leading his parents to believe that he had moved past his "phase", but recently, the repetitive grunting and jumping behaviors have resurfaced. Introduction Overview Tourette syndrome is a neuropsychiatric disorder with an onset before age 18 that is characterized by motor and vocal tics for >1 year tics are sudden, rapid, recurrent, and nonrhythmic tics may wax and wane in frequency Epidemiology incidence ~3 cases per 1,000 people demographics male:female ratio is 5:1 most common age for tic onset is 9-14 years Pathophysiology remains unknown, but the basal ganglia and inferior frontal cortex have been implicated in the pathophysiology of Tourette syndrome Genetics majority of cases are familial prevalence in first-degree relatives is 10 times the prevalence in the general population Associated conditions obsessive-compulsive disorder ADHD Prognosis about half of patients are free of tics by age 18 years severity of tics peaks in early-to-mid adolescence and diminishes afterwards Presentation Symptoms multiple motor and vocal tics that occur many times a day every day or intermittently for > 1 year simple motor blinking, nose sniffing, neck twitching, or jerking/posturing of extremities complex motor hitting, jumping, shaking, touching, or performing a motor task simple vocal grunting, coughing, or throat clearing complex vocal words or phrases coprolalia (obscene speech) seen in only a minority of patients Studies No further workup is necessary if typical indications of Tourette syndrome are observed in the patient's history Differential Wilson disease key distinguishing factor Kayser-Fleischer rings observed on slit lamp examination, along with other clinical features of Wilson disease Treatment Lifestyle education and counseling about tics indication mild and non-disabling tics habit reversal training indication tics that cause psychosocial, physical, functional, or other problems Medical antidopaminergic drugs (i.e., haloperidol, pimozide, or aripiprazole) indications complex or multiple tics α2 agonists (i.e., clonidine and guanfacine) indications patients with Tourette syndrome who also have attention deficit hyperactivity disorder (ADHD)