The Corona virus disease 2019 (COVID-19) has had a profound impact on the physical as well as mental well-being of people around the globe. The response to and resulting consequences of the COVID-19 pandemic poses significant challenges for patients suffering from mental health disorders as demonstrated by a recent study by Xie et al. examining adult COVID-19 patients admitted for inpatient psychiatric treatment for first-episode mental health issues [1]. Children, too, have the potential to experience adverse mental health outcomes due to distress resulting from the pandemic: a study by Jolly et al. examined recently surfacing reports on varied presentations of pediatric patients undergoing hospitalization in psychiatry hospitals in context of COVID-19. One major source of stress is the institution of widespread social distancing practices as schools have transitioned to partial or full-time virtual learning [2]. In addition, extracurricular activities have undergone restrictions or been canceled entirely and in-person contact with peers and other important social supports has been limited. These changes place strain on children which can lead to distress and worsening mental health outcomes [2]. The pandemic has also caused significant economic stress for many families. Increased unemployment, forced changes in interpersonal interactions, the wide-ranging effects caused by the safety measures being taken in response to COVID-19, and even concern over COVID-19-related illness or death itself may directly impact the mental health of children as well as indirectly impacting their mental health due to increased stress experienced by parents and the family as a whole [2]. Moreover, children who become COVID-positive and are subject to specific safety protocols in their care are under additional pressure that can further exacerbate mental health problems related and unrelated to the COVID-19 pandemic. There have been limited studies evaluating the treatment of COVID-19 pediatric patients admitted for the treatment of mental health disorders [3,4]. Here we present two cases of COVID-positive pediatric patients in an inpatient psychiatric facility and how the milieu was changed around them.

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The COVID-19 pandemic has led to a multitude of new medical and psychiatric complications and new presentations that were either never seen before or not seen to the extent that they are presenting now. [1,2]. Increased number of suicide attempts and worsening severity of suicide attempts have been noted in the past year since the COVID-19 pandemic has started [1]. Psychotropic medications can often have lesser-known side effects and movement disorders, including tics, can be one of them [3]. Tics are recurrent, simple or complex behaviors that can be motor or phonic in nature [4,5]. Simple motor tics are often observed as rapid movements while complex motor tics are more synchronized and elaborate. Additionally, noises or brief sounds are examples of simple vocal tics, while speaking a string of words or syllables are more characteristic of a complex vocal tic [4]. The underlying pathogenesis of tics and tic disorders has not been well elucidated, dopaminergic hypothesis being the most widely accepted; however, multiple areas of the brain are speculated to be involved [4,6]. Common treatment options for tic disorders include alpha-2 agonists, clonidine and guanfacine, and antipsychotics [4,7]. Previous literature identifies two case reports that documented tics related to quetiapine. One report described a pediatric bipolar patient who developed tics proportional to quetiapine dose [8], and the other report identified an adult patient with schizophrenia who developed tics during quetiapine therapy [9]. In this article, we describe a pediatric patient who presented after overdosing on quetiapine, lamotrigine and sertraline and developed tics after re-initiation of quetiapine at a much lower dose. To the best of our knowledge, this is the first case of its kind where tics, which were previously absent, developed on re-initiation of quetiapine after an overdose.