Abstract
Objective
This study aims to characterise the clinical profiles and pharmacotherapeutic choices among children with newly diagnosed tic disorders (TDs) in China in order to improve clinical understanding and support decision-making for clinicians.
Methods
This was a retrospective cohort study involving 15 182 paediatric patients aged 4–18 years newly diagnosed with TD at Wuhan Children’s Hospital between January 2021 and October 2024. Demographic characteristics and initial pharmacotherapy choices were collected and analysed. Clinical characteristics were compared across age (<6 years, 6–12 years and ≥12 years) and gender groups using χ2 tests/Wilcoxon rank-sum tests and trend analyses. A generalised linear model was applied to analyse the trend in the male-to-female ratio with increasing age. Pharmacotherapy choices were also analysed and divided into monotherapy and combination therapy for further evaluation.
Results
Among the patients, 78.6%, 9.9% and 11.5% were diagnosed with provisional TD, chronic TD (CTD) and Tourette syndrome (TS), respectively. The median age at diagnosis was 7.3 years, with a male-to-female ratio of 3.7:1. The most common symptom was eye blinking/eye rolling. The rate of premonitory urge and the tic-related impact tended to increase with age. Male patients showed a higher prevalence of CTD and TS, as well as a greater comorbidity rate of attention-deficit/hyperactivity disorder. And the rate of male patients was slightly positively correlated with age at onset. Most patients chose the monotherapy for the first time. Among them, the clonidine patch and traditional Chinese medicine were the most common choices.
Conclusions
We described the clinical phenotypes of paediatric patients with newly diagnosed TD in China. At the same time, we also explored the differences in TD subtypes, clinical characteristics and medication choices between patients in different age and gender groups, providing valuable real-world evidence for an early identification and individualised treatment in paediatric TD.
Keywords: Child Health, Epidemiology, Neurology
WHAT IS ALREADY KNOWN ON THIS TOPIC
Tic disorders (TDs) are neuropsychiatric conditions which have adverse effects on children’s physical and mental health. Diagnostic delays occur due to variable symptoms. Timely diagnosis can relieve tic symptoms and improve the quality of life for children with TD. However, the specific choices of medications vary between individuals, depending on the preferences of the clinicians and caregivers.
WHAT THIS STUDY ADDS
This large retrospective cohort study in China (15 182 children newly diagnosed with TD) indicates that males are more prone to chronic subtypes (chronic TD (CTD)/Tourette syndrome (TS)) and attention-deficit hyperactivity disorder (ADHD). Eye blinking/rolling (60.2%) is the most common symptom. With age, provisional TD tends to decrease, while CTD/TS, premonitory urges and comorbid ADHD seem to rise. The clonidine patch and traditional Chinese medicine are the most common choices.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
It enhances the scientific understanding of clinical phenotypes in paediatric TD, including age-specific and gender-specific symptom profiles and comorbidity patterns, and clarifies real-world pharmacotherapeutic practices in treatment-naïve populations. This improved characterisation facilitates more precise differential diagnosis, particularly for early diagnosis of TD in children. It also supports targeted research and informs China’s TD guidelines by reflecting actual clinical practices.
Introduction
Tic disorders (TD) are neuropsychiatric conditions characterised by involuntary and rapid motor and/or phonic tics. Based on the courses and manifestations, TD is classified into three subtypes: provisional TD (PTD), chronic TD (CTD) and Tourette syndrome (TS).1 2 These patients often have comorbidities including attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), oppositional defiant disorder, sleep problems, anxiety and depression disorders. The onset of TD typically occurs between 4 and 7 years of age, peaks around 10–12 years, and tends to attenuate after puberty.2,5 Current evidence indicates that the incidence of TD is on the rise.6 Epidemiological studies report that 11%–20% of school-aged children transiently experience TD, while the global prevalence of TS is estimated at 0.3%–1.0%.1 3 7 TDs are more common in boys, with the sex ratio approximated to 3–5:1 (male vs female) in childhood, while this ratio seems to narrow in adulthood.2 3 8
Both TDs and their comorbidities have adverse effects on children’s physical and mental health. The interval between tic onset and diagnosis can be quite long due to neglect or misunderstanding of these symptoms. Diagnostic difficulties may occur due to the fluctuating characteristics of tics as well as their symptom variability.9 Timely diagnosis can relieve tic symptoms and improve the quality of life (QoL) for children with TD. Pharmacotherapy now serves as one of the initial and primary treatments for moderate to severe TD. A foreign study found that patients with TS received pharmacotherapy more frequently than those with PTD and CTD.8 However, the specific choices of medications vary between individuals, depending on the preferences of the clinicians and decisions of caregivers (eg, Chinese parents may tend to favour traditional Chinese medicine (TCM)).10,12 Globally, aripiprazole, tapride and clonidine are the frequently used first-line drugs, and risperidone is selected as a second-line drug.39 11,13 Additionally, TCM therapies have also been recommended as the first-line treatment options for TD in China, according to a national guideline by a TD expert committee.14
In this study, we describe the clinical phenotype of paediatric patients with newly diagnosed TD in China. At the same time, we also explore the differences in TD subtypes, clinical characteristics and medication choices between patients in different age and gender groups, providing valuable real-world evidence for early identification and individualised treatment in paediatric TD.
Methods
Participants
This retrospective cohort study included children aged 4–18 years who were newly diagnosed with TD at Wuhan Children’s Hospital for the first time between January 2021 and October 2024, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
A total of 15 182 children were enrolled. Demographic and clinical information included gender, the age at onset and diagnosis, the duration of TD, family history of TD, TD subtypes, tic symptoms, comorbidities and pharmacotherapy choices. The duration of TD was defined as the time interval between symptom onset and initial diagnosis. The diagnoses of comorbidities, such as ADHD, OCD, autism spectrum disorder (ASD) and anxiety and depression disorders, were based on the criteria of DSM-5 by a paediatric neurologist or psychiatrist.
All the information of the patients was retrieved from the scientific research data platform of Wuhan Children’s Hospital, specifically from its specialised database for TD. This platform has preset safeguards to protect the patients’ privacy.
Patient and public involvement
Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Statistical analysis
All the data were analysed in R V.4.4.2. Categorical variables were presented as frequencies and percentages. Normally distributed continuous variables were expressed as mean±SD, while non-normally distributed variables were reported as median (25th–75th percentiles).
For analysis of clinical information, the age at first diagnosis was categorised into preschool-age (<6 years), school-age (6–12 years) and adolescent (≥12 years) groups. Using χ2 tests, we compared the differences in the clinical types and tic-related impact of TD (the patients reported that tics impair their life and study), premonitory urge and tic symptoms and comorbidities among these three groups. For indicators with statistically significant differences, trend analyses were applied to explore their tendency with age.
Stratified by gender, differences in clinical types, age at onset and diagnosis, premonitory urge, the five most common symptoms, the comorbidity of ADHD and family history were compared using χ2 tests/Wilcoxon rank-sum tests. A study reported that with the increase in age, the ratio of male-to-female patients seemed to gradually decrease.15 To evaluate this trend, a generalised linear model was employed, incorporating both gender and age as factors. In addition, we investigated the ratio of patients with comorbid ADHD across clinical subtypes.
Regarding the pharmacotherapy choices of paediatric patients newly diagnosed with TD, we excluded those who refused pharmacotherapy or did not require pharmacotherapy at the initial diagnosis. Among the remaining 8291 cases included, treatment regimens were categorised into monotherapy and combination therapy. The frequency of each prescribed medication for TD was calculated. Then, the differences in monotherapy and combination therapy between different clinical subtypes and age groups were statistically analysed.
For the statistical analyses mentioned above, we adopted a significance level of 0.05, used two-sided p values and implemented Bonferroni correction for multiple comparisons.
Results
Clinical characteristics in paediatric patients newly diagnosed with TD
Demographic characteristics
A total of 15 182 patients were included in the study, comprising 11 923 males and 3259 females (the male-to-female ratio was 3.7:1). Among the patients first diagnosed with TD, 78.6% (n=11 932), 9.9% (n=1504) and 11.5% (n=1746) were diagnosed with PTD, CTD and TS, respectively. The median age at TD diagnosis was 7.3 years (5.6, 9.1), while the median age at tic onset was 6.7 years (5.2, 8.5). Among the patients, 38.1% (n=5781), 59.9% (n=9098) and 2.0% (n=303) developed TD during preschool age, school age and adolescence, respectively. The median duration of TD was 2.0 months (0.7, 6.0) (table 1).
Table 1. The clinical characteristics of the paediatric patients diagnosed with TD for the first time.
| N (%)/median (25th–75th percentile) | Number (%) (N=15 182) |
|---|---|
| Sex ratio (male:female) | 3.7 (11 923:3259) |
| Age (years) at onset | 6.7 (5.2, 8.5) |
| Age (years) at diagnosis | 7.3 (5.6, 9.1) |
| The duration of TD (months) | 2.0 (0.7, 6) |
| Subtypes of TD | |
| PTDs | 11 932 (78.6) |
| CTDs | 1504 (9.9) |
| TS | 1746 (11.5) |
| Tic symptom | |
| Eye blinking/eye rolling | 9139 (60.2) |
| Jaw/lip movement/spitting | 3713 (24.3) |
| Head movement | 3302 (21.7) |
| Throat clearing | 2806 (18.5) |
| Grunting | 2330 (15.4) |
| Shoulder movement | 1171 (7.7) |
| Nose wrinkling | 1544 (10.2) |
| Neck movement | 1447 (9.5) |
| Sniffing | 1367 (9.0) |
| Grimacing | 1182 (7.8) |
| Hand movement | 850 (5.6) |
| Trunk movement | 696 (4.6) |
| Abdomen movement | 609 (4.0) |
| Eyebrow movement | 450 (3.0) |
| Coughing | 302 (2.0) |
| Leg movement | 271 (1.8) |
| Sighing | 237 (1.6) |
| Arm movement | 213 (1.4) |
| Coprolalia | 45 (0.3) |
| Walking halt | 43 (0.3) |
| Premonitory urge | 505 (3.3) |
| Family history of TD | 249 (1.6) |
| Age at onset | |
| Preschool (<6 years) (n=5781 (38.1)) | 4.77 (3.9, 5.4) |
| School age (6–12 years) (n=9098 (59.9)) | 7.93 (6.9, 9.2) |
| Adolescence (≥12 years) (n=303 (2.0)) | 12.66 (12.3, 13.5) |
| Comorbid disorder | |
| ADHD | 1213 (8.0) |
| Epilepsy | 86 (0.6) |
| ASDs | 45 (0.3) |
| Intellectual disability/borderline intellectual functioning | 59 (0.4) |
| OCD | 15 (0.1) |
| Anxiety disorder | 24 (0.2) |
| Depression disorder | 34 (0.2) |
ADHD, attention-deficit hyperactivity disorder; ASD, autism spectrum disorder; CTD, chronic tic disorder; OCD, obsessive-compulsive disorder; PTD, provisional tic disorder; TD, tic disorders; TS, Tourette syndrome.
The most common symptoms included eye blinking/eye rolling (60.2%), followed by jaw/lip movement/spitting (24.3%), head movement (21.7%), throat clearing (18.5%) and grunting (15.4%). The most common comorbidity was ADHD (8.0%), followed by epilepsy (0.6%) and ASD (0.3%) (table 1).
Instead of receiving a TD diagnosis in neurology or psychiatry departments, 2394 patients with tic symptoms first visited other departments due to misunderstandings. A total of 1632 patients visited the ophthalmology department because of their eye blinking or rolling symptoms. 482 patients visited the otolaryngology department due to their nose wrinkling or sniffing and throat-clearing symptoms. The remaining cases presenting with symptoms, such as coughing, but treated in departments other than neurology or psychiatry, are presented in table 2.
Table 2. The departments visited before the confirmed diagnosis.
| Department | Frequency |
|---|---|
| Ophthalmology department | 1632 |
| Otolaryngology department | 482 |
| Respiratory medicine department | 202 |
| Orthopaedics department | 56 |
| Gastroenterology department | 17 |
| Cardiovascular department | 3 |
| Stomatology department | 2 |
Clinical features of TD in different age groups
Patients were divided into three groups based on age at first diagnosis (preschool, school-age and adolescent groups). With increasing age, PTD (preschool: 90.5% vs school age: 74.6% vs adolescence: 53.2%) seemed to exhibit a decreasing trend, whereas both CTD (preschool: 4.4% vs school age: 11.6% vs adolescence: 24.5%) and TS (preschool: 5.1% vs school age: 13.8% vs adolescence: 22.3%) tended to demonstrate an increasing trend. Besides, a trend showed that premonitory urges were more common in adolescents (4.8%) and school-age (3.7%) groups than in the preschool (2.5%) group (Z=4.68, p for trend <0.01). Likewise, the rate of tic-related impact among the adolescent (16.8%), school-age (15.7%) and preschool-age (8.8%) groups followed a similar trend (Z=10.95, p for trend <0.01). Furthermore, the trend analysis indicated that with the increasing age, eye blinking/eye rolling and jaw/lip movement/spitting gradually seemed to decrease, while head movement, throat clearing and grunting gradually seemed to increase (all p for trend <0.01). As shown in table 3, the rate of ADHD comorbidity increased with ageing (Z=12.57, p for trend <0.01).
Table 3. Analysis based on the age at diagnosis (preschool (<6 years), school-age (6–12 years) and adolescent (≥12 years) groups).
| N (%) | Preschool (N=4604) |
School age (N=10 000) |
Adolescence (N=578) |
P value |
|---|---|---|---|---|
| PTDs | 4164 (90.5) | 7461 (74.6) | 307 (53.2) | ＜0.01 |
| CTDs | 204 (4.4) | 1158 (11.6) | 142 (24.5) | |
| TS | 236 (5.1) | 1381 (13.8) | 129 (22.3) | |
| Premonitory urge* | 108 (2.5) | 369 (3.7) | 28 (4.8) | ＜0.01 |
| Tic-related impact* | 406 (8.8) | 1574 (15.7) | 97 (16.8) | ＜0.01 |
| Eye blinking/eye rolling* | 2980 (64.7) | 5864 (58.6) | 295 (51.0) | ＜0.01 |
| Jaw/lip movement/spitting* | 1261 (27.4) | 2328 (23.4) | 124 (21.5) | ＜0.01 |
| Head movement* | 778 (16.9) | 2374 (23.7) | 150 (26.0) | ＜0.01 |
| Throat clearing* | 764 (16.6) | 1939 (19.4) | 103 (17.8) | ＜0.01 |
| Grunting* | 587 (12.8) | 1653 (16.5) | 90 (15.6) | ＜0.01 |
| Comorbid ADHD* | 156 (3.4) | 1004 (10.0) | 53 (9.2) | ＜0.01 |
Trend analysis: premonitory urge (Z=4.68); tic-related impairment (Z=4.68); eye blinking/eye rolling (Z=−8.32); jaw/lip movement/spitting (Z=−5.52); head movement (Z=9.53); throat clearing (Z=3.33); grunting (Z=5.52); ADHD (Z=12.57); and all p<0.01.
ADHD, attention-deficit hyperactivity disorder; CTD, chronic tic disorder; PTD, provisional tic disorder; TS, Tourette syndrome.
Considering clinical subtypes, the prevalence of comorbid ADHD was higher in CTD (12.5%) and TS (13.4%) compared with PTD (6.7%) (pairwise group comparison p<0.01 (p=0.17 after Bonferroni correction) for CTD vs PTD and TS vs PTD). However, the rate of comorbidity of ADHD between TS and CTD groups (p=0.47) was not statistically significant.
We compared the rates of TD subtypes between genders, finding that male patients tended to undergo CTD (including CTD and TS) (10.0% and 12.1%, respectively) more than female patients (9.6% and 9.4%, respectively) (χ²=19.53, p<0.01). Regarding tic symptoms, eye symptoms, head movement and grunting were more common in male than female patients (p<0.05). The onset age was seemingly slightly earlier in female than male patients (6.3 vs 6.8 years, p<0.01), as well as the age at diagnosis (6.8 vs 7.4 years, p<0.01) (table 4).
Table 4. Analysis based on the gender group.
| N (%)/median (25th–75th percentile) | Male patients (N=11 923) |
Female patients (N=3259) | P value |
|---|---|---|---|
| CTDs | 1191 (10.0) | 313 (9.6) | <0.01 |
| PTDs | 9292 (77.9) | 2640 (81.0) | |
| TS | 1440 (12.1) | 306 (9.4) | |
| Premonitory urge | 394 (3.3) | 111 (3.4) | 0.77 |
| Eye blinking/eye rolling | 7262 (60.9) | 1877 (57.6) | 0.01 |
| Jaw/lip movement/spitting | 2936 (24.6) | 777 (23.8) | 0.35 |
| Head movement | 2657 (22.3) | 645 (19.8) | 0.01 |
| Throat clearing | 2227 (18.7) | 579 (17.8) | 0.23 |
| Grunting | 1867 (15.7) | 463 (14.2) | 0.04 |
| Age at symptom onset* | 6.8 (5.3, 8.6) | 6.3 (4.7, 8.0) | <0.01 |
| Age at diagnosis* | 7.4 (5.7, 9.2) | 6.8 (5.2, 8.6) | <0.01 |
| Comorbid ADHD | 1076 (9.0) | 137 (4.2) | <0.01 |
| Family history of TDs | 168 (1.4) | 81 (2.5) | <0.01 |
The Wilcoxon rank-sum test is adopted.
ADHD, attention-deficit hyperactivity disorder; CTD, chronic tic disorder; PTD, provisional tic disorder; TD, tic disorder; TS, Tourette syndrome.
A previous study has demonstrated that the male-to-female ratio in TD incidence exhibited a significant decreasing trend with advancing age.15 Moreover, epidemiological studies on TD have reported that the observed decline in male predominance in TD with increasing age has also been noted.16
But as shown in figure 1, the male-to-female ratio increased from 2.9 to 4.9. Also, the generalised linear model showed that the rate of male patients was slightly positively correlated with age at onset (β=0.09, p<0.01).
Figure 1. The gender ratio (male:female) of participants in different age groups (preschool group (<6 years), school-age group (6–12 years) and adolescent group (≥12 years)).
Pharmacotherapy choices in patients first diagnosed with TD
The majority of patients (n=9380, 61.8%) chose pharmacotherapy for the first time (mostly monotherapy (n=6505, 69.4%)). Among patients with PTD (n=11 932), 7002 (58.9%) chose pharmacotherapy (5128 (73.2%) chose monotherapy vs 1874 (26.8%) chose combination therapy). Among patients with CTD (n=1504), 1018 (67.7%) chose pharmacotherapy (644 (63.3%) chose monotherapy vs 374 (36.7%) chose combination therapy). Among patients with TS (n=1746), 1360 (77.9%) chose pharmacotherapy (733 (53.9%) chose monotherapy vs 627 (46.1%) chose combination therapy). Actually, it seemed that patients diagnosed with TS (46.1%) were more likely to choose combination therapy compared with those with CTD (36.7%) and PTD (26.8%) (χ²=220.29, p<0.01). Patients with comorbid ADHD were more likely to receive pharmacotherapy (78.81% vs 60.30%; χ²=161.13, p<0.01) and combination therapy (40.16% vs 29.57%; χ²=255.02, p<0.01) compared with those without ADHD.
In monotherapy, the clonidine adhesive patch (CAP) was the most frequently prescribed (56.6%), followed by TCM (including Changma Xifeng Tablets, Shaoma Zhijing Granules or Jiuwei Xifeng Granules) (table 5). Notably, risperidone can improve the patients’ social functioning in the short term.17 And antiseizure medicines, such as nitrazepam and clonazepam, are also combined with other first-line drugs in TD, aimed to control phonic tics in severe cases.18 We included 9 patients who were treated with a combination, including risperidone or antiseizure medicines.
Table 5. Pharmacotherapy choices for paediatric patients diagnosed with TDs for the first time.
| Monotherapy group (n=6505) | Frequency (n) | Percentage (%) |
|---|---|---|
| CAP | 3672 | 56.6 |
| TCM | 2528 | 38.9 |
| Aripiprazole | 142 | 2.3 |
| Tiapride | 163 | 2.2 |
| The combination therapy group (n=2875) | ||
| CAP+TCM | 1682 | 58.5 |
| CAP+antipsychotic | 533 | 18.5 |
| TCM+antipsychotic | 308 | 10.7 |
| TCMs (n=2) | 17 | 0.6 |
| Antipsychotics (n=2) | 2 | 0.1 |
| Others (n≥3) | 333 | 11.6 |
CAP, clonidine adhesive patch; TCM, traditional Chinese medicine; TD, tic disorder.
Then, we summarised the combinations of different drugs, finding that CAP or TCM was often combined with other antipsychotics at the initial diagnosis. The proportion of patients opting for treatment involving three or more medications was quite small (n=333). Furthermore, the utilisation of combination therapy increased significantly with older age at diagnosis (Z=14.65, p for trend <0.01).
Discussion
Involuntary and rapid tics are common in childhood and adolescence, and a significant diagnostic delay often exists between symptom onset and diagnosis.3 Approximately only 73% of patients with TD receive a proper diagnosis initially, due to the complexity and fluctuation of tic symptoms.11 18 19 Timely diagnosis not only helps relieve tic symptoms but also improves QoL.11 Consequently, we attempt to illustrate the clinical features and initial medication choices to help make a precise diagnosis for the first time.
The median age at TD diagnosis is 7.3 years, lagging behind its median age at onset (6.7 years), with the sex ratio of 3.7:1 (male vs female). And previous studies confirmed that tics often originated at the head and face, with blinking/eye rolling being the most frequent tic symptoms (more than 50%).11 20 And in our cohort, eye blinking (more than 50%) is the most common tic symptom, and a large number of children (10.7%) initially seek help at the ophthalmology department. Actually, the incidence of eye blinking symptoms in patients with TD ranges from 50.4% to 83.6%, suggesting that eye tics are likely to be a core feature of TS.21,23 In a study by Tang et al, involving 1054 patients with abnormal eye blinking symptoms, 453 (43.0%) were diagnosed with TD, and among them, 121 (26.7%) were initially misdiagnosed (mainly as allergic conjunctivitis) or overlooked.21 This reminds clinicians that for patients presenting with eye blinking and ocular discomfort, TD should not be ruled out even if an ocular disease is diagnosed.
Over 80% of patients with tics report a premonitory urge, which involves distinct cognition, emotion or local sensations/discomfort.24 25 In our study, only about 3.3% of patients reported a premonitory urge. This may be attributed to the fact that young children in our study are incapable of accurately describing the urges. In clinical practice, older children report premonitory urges more frequently, with the mean age being 10 years when children report the symptoms of premonitory urges.25 We find an increasing trend from the preschool group to the adolescent group of children reporting premonitory urges.
Among all the comorbidities of TD, ADHD is the most prevalent and has the earliest onset (median age 5 (IQR 3–6) years).18 In our study, the rate of comorbid ADHD in children with TS is higher than in PTD and CTD (though TS vs CTD p=0.47). Previous studies reported that the odds of comorbid ADHD were generally lower in PTD and CTD than in TS.4 26 A stronger genetic linkage between TS and ADHD may provide a potential explanation for this association.27 Moreover, the comorbidity rate of ADHD in male patients with TD is significantly higher than that in female patients (9.0% vs 4.2%, respectively, p<0.01).
Although a well-documented male predominance has been reported in patients with TS, less is known regarding sex differences across patients with TD.15 28 Our study finds that male children are more likely to have CTDs (including CTD and TS) compared with female patients. And the rates of eye blinking/eye rolling, head movement and grunting are slightly higher in male patients than female patients. In addition, the male-to-female ratio seems to gradually increase with age. The generalised linear model also reveals a positive correlation between the age at onset and a higher proportion of male patients. However, other studies found that the proportion of females increased with age.15 29 The relative increase in the female proportion of TD appears to be driven by an age-dependent relative decrease in men and a lack of change or increase in female patients.13 But different from these studies, this study only includes children under the age of 18 years, which may not reach that time point (the time point at which the prevalence rate of male children begins to decline). The formation of the differences in this study may be related to the age of the research subjects included.
Regarding medications for TD, treatment decisions, including whether to initiate pharmacotherapy and which agents to use, depend on clinicians’ clinical judgement and guardians’ preferences.18 In clinical practice, specific tools can be used to assess health-related QoL (HR-QOL) impairment, aiding decisions on whether and when to initiate pharmacotherapy. Among these tools, the Gilles de la Tourette Syndrome-Quality of Life Scale for children and adolescents is a well-validated, disease-specific HR-QOL measure designed for paediatric patients with TS. Comprising 27 items across four subscales (psychological, physical, obsessive-compulsive and cognitive), it uniquely captures the nuanced impact of TS symptoms on daily functioning, making it particularly useful for guiding personalised treatment decisions.30
In our study, CAP was the most frequently prescribed monotherapy. Consistent with a study in Canada, the use of clonidine has gradually increased in recent years and is now the most frequently used.12 However, a previous study found that the most commonly prescribed medications were antipsychotics (38.8%), followed by clonidine adhesive and CAP (31.7%) and TCM (29.5%) from 2018 to 2020, in Beijing Children’s Hospital, based on all visits of patients with TD.31 This discrepancy may be explained by the fact that Wang et al’s31 study did not include only newly diagnosed children. For adolescent patients, tic symptoms often persist, and many have previously tried CAP and TCM; this could account for the higher rate of antipsychotic use observed in their results.28
Additionally, combination therapy is more common in patients with TS than in patients with CTD and PTD. We speculate that patients with TS experience more diverse and complex tic symptoms than those with CTD and PTD, which may necessitate a multi-agent pharmacological approach to achieve adequate symptom control. Besides, compared with younger children, older children are more inclined to choose combination pharmacotherapy. We make an assumption that older children may tend to experience premonitory urges (ie, discomfort) and the impairment to their dignity and QoL, thereby justifying the use of more intensive treatment strategies.
Our study is limited by its retrospective nature. We obtained data from a single centre, and there is a lack of prospective observation, though the large sample size confers strong internal validity. Notably, the findings of this study reflected the clinical status of newly diagnosed paediatric TD in China, which might have certain regional characteristics specific to the Chinese context and might not be directly generalised to other countries or regions with different medical practices, cultural backgrounds or healthcare systems. Second, we only explored medications for TD and did not investigate medications used to treat comorbidities (such as ADHD or OCD), which limited the discussion on comorbidities in this article. Therefore, further prospective and multi-centre clinical studies are greatly needed to make a thorough depiction of TD symptoms and evaluate therapy efficacy.
Conclusions
We described the clinical phenotype of paediatric patients with newly diagnosed TD in China. At the same time, we also explored the differences in TD subtypes, clinical characteristics and medication choices between patients in different age and gender groups, providing valuable real-world evidence for early identification and individualised treatment in paediatric TD.
Footnotes
Funding: This work was supported by the National Key Research and Development Plan (2021YFC0863700) and Hubei Provincial Science and Technology Plan Project for Clinical Research Center of Neurodevelopmental Disorders in Children (2022DCC020).
Data availability free text: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request at liuzhisheng@hust.edu.cn.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants and was approved by the ethics committee of Wuhan Children’s Hospital (No. 2025R013-E01) according to the Measures for the Ethical Review of Biomedical Research Involving Humans in China, and all patient privacy was strictly protected throughout the research process. Participants gave informed consent to participate in the study before taking part.
Provenance and peer review: Not commissioned; internally peer reviewed.
Patient and public involvement: Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Data availability statement
Data are available upon reasonable request.
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Associated Data
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Data Availability Statement
Data are available upon reasonable request.