When tics are not the whole story: rethinking clinical assessment in children with tic disorders

Abstract

Tic disorders are heterogeneous neurodevelopmental conditions in which observable tic severity does not necessarily reflect the difficulties that most affect the child’s everyday life. Premonitory sensations, pain, suppression effort, psychiatric symptoms, motor or sensory features, and executive vulnerabilities may contribute differently to clinical presentation and functional outcomes. In this Perspective, we propose a three-domain clinical framework that distinguishes: (1) observable tic phenomenology and severity; (2) subjective tic-related experience; and (3) the broader neurodevelopmental and psychiatric profile. The framework is intended as a clinical heuristic for organizing assessment and prioritization rather than as a validated dimensional model. Functional impairment, participation, adaptive functioning, and health-related quality of life are considered transversal outcomes through which the clinical relevance of each domain should be evaluated. We argue that assessment should remain selective and focused on findings with meaningful functional consequences. Clinical priorities should therefore be determined not by tic visibility alone, but by the modifiable factors most strongly associated with meaningful functional consequences. This approach may support more individualized, developmentally informed, and child-centered treatment goals while providing a framework whose clinical usefulness can be evaluated empirically.