What treatment and referrals are recommended for an 11-year-old female with an 8-month history of eye rolling, suspected to be a tic disorder, after neurology (neuro) and ophthalmology (optho) evaluations have ruled out vision and neurological issues?

Management of Eye Rolling in an 11-Year-Old Female with Suspected Tic Disorder

Direct Recommendation

Initiate behavioral therapy with habit reversal training or exposure and response prevention as first-line treatment, screen comprehensively for ADHD and OCD comorbidities, and refer to a pediatric neurologist or child psychiatrist specializing in movement disorders for ongoing management. 1, 2

Initial Diagnostic Confirmation

Since neurology and ophthalmology have already ruled out structural and neurological causes, the clinical diagnosis of a tic disorder can be made based on DSM criteria without excessive additional medical testing to avoid iatrogenic harm. 1 The eye rolling represents a motor tic—characterized as a very brief jerk or dystonic posture that is sudden, rapid, stereotyped, and apparently purposeless. 1, 3

Key diagnostic features to confirm:

• Duration of symptoms (8 months meets criteria for chronic tic disorder if no vocal tics present, or provisional Tourette syndrome if vocal tics develop) 1
• Presence of premonitory urges before the eye rolling (occurs in over 80% of patients with tics) 4, 3
• Waxing and waning pattern with exacerbation during stress, anxiety, or fatigue 3
• Improvement during focused activities or sleep 5, 3

Essential Comorbidity Screening

This is critical and often more impairing than the tics themselves:

• Screen for ADHD: Present in 50-75% of children with tic disorders and often causes more functional impairment than tics alone 1, 2, 3
• Screen for OCD or obsessive-compulsive behaviors: Present in 30-60% of patients with tic disorders 1, 2, 3
• Assess for anxiety disorders and impulse control problems: 90% of children with tic disorders have comorbid conditions 3

Treatment Algorithm

First-Line: Behavioral Interventions

Behavioral therapy should be offered before pharmacological treatment unless tics are severely functionally impairing. 1, 2

• Habit reversal training (HRT): Teaches awareness of premonitory urges and competing responses 1, 2
• Exposure and response prevention (ERP): Specifically recommended as first-line behavioral therapy 1, 2
• These approaches are effective for many individuals and avoid medication side effects 5

Second-Line: Pharmacological Treatment

Reserve medications for patients who fail behavioral approaches or have severe functional impairment. 2

Initial pharmacotherapy:

• Clonidine (first choice): Start 0.05 mg at bedtime, increase by 0.05 mg every 4-7 days as needed to maximum 0.3-0.4 mg/day divided 3-4 times daily 5
  • Particularly advantageous if ADHD is comorbid, as it treats both conditions simultaneously 1, 2
  • Reasonable safety profile compared to antipsychotics 5
• Guanfacine (alternative alpha-2 agonist): Start 0.5 mg at bedtime, increase by 0.5 mg weekly to maximum 3-4 mg/day divided twice daily 5

If alpha-agonists prove insufficient:

• Atypical antipsychotics (preferred over typical neuroleptics):
  • Risperidone (first choice): Start 0.01 mg/kg/dose once daily, increase by 0.02 mg/kg/day weekly up to 0.06 mg/kg/dose once daily 5
  • May also help with behavioral problems that accompany tics 5
  • Alternatives include olanzapine or ziprasidone 5, 4
• Typical antipsychotics (most potent but more side effects): Haloperidol, pimozide, or fluphenazine—reserve for severe cases unresponsive to atypicals 1, 2, 5

Referral Strategy

Refer to pediatric neurology or child and adolescent psychiatry specializing in movement disorders for:

• Comprehensive neuropsychiatric assessment 1
• Initiation and monitoring of behavioral therapy 1, 2
• Medication management if behavioral therapy fails 2
• Long-term monitoring, as tics typically begin around age 7 and may evolve 4

Consider additional referrals based on comorbidities:

• Neuropsychology for formal ADHD/OCD testing if screening is positive 1
• School accommodations and support services 3

Critical Pitfalls to Avoid

• Never dismiss tics as "habit behaviors" or "psychogenic symptoms"—this delays proper treatment and causes harm 2
• Do not start with antipsychotics—behavioral therapy and alpha-agonists should be tried first unless tics are severely disabling 1, 2
• If ADHD is comorbid and requires treatment, stimulants may be used with proper informed consent—they do not worsen tics in most cases, though methylphenidate is preferred over amphetamine-based medications 1, 2
• Avoid excessive medical testing—diagnosis is clinical and unnecessary investigations cause iatrogenic harm 1
• Address comorbidities aggressively—they often cause more impairment than the tics themselves and require specific treatment 5, 3

Prognosis and Counseling

Educate the family that many tics do not interfere significantly with daily life and may not require specific treatment beyond behavioral strategies. 5 The ability to tolerate tics varies greatly, and treatment decisions should be guided by the patient's and family's distress level rather than tic severity alone. 4 Tics typically wax and wane, and some children experience improvement or resolution over time. 3