Tics and Tourette Syndrome in Children

The exact cause of tics isn't known. They are likely due to a mix of genetic and environmental factors. Neurotransmitters (like dopamine) and brain areas (like the basal ganglia) are also believed to play a role.

Tics are classified as either motor or vocal and either simple or complex. 

Motor Tics

Motor tics are characterized by uncontrolled, repetitive movements of a group of muscles.

Common motor tics include:

• Eye blinking/movements
• Nose scrunching/movements
• Facial grimace
• Head jerk
• Rotating
• Hand movements

Simple motor tics involve only one muscle group, such as twitching the nose or head, blinking the eye, or biting the lip. Complex motor tics could include kicking, jumping, or mimicking movements, which require multiple muscle groups. 

Vocal Tics

Vocal tics are characterized by sudden, involuntary sounds or noises.

Common vocal tics include: 

• Coughing
• Throat clearing
• Sniffing
• Animal sounds
• Repeated syllables

Simple vocal tics may include coughing and throat clearing, barking, or hissing.

Complex vocal tics, however, could include repeating whole words or phrases, making animal sounds, or yelling out; words or phrases may be recognizable but are always out of context. In some cases, they may be inappropriate (i.e., curses, slurs, etc.). This type of vocalization is called coprolalia. Although often thought to be common, it only happens in about 10% of people with vocal tics.

Like all psychological disorders, tics and tic-like behaviors rise to the level of being a disorder when they start to cause clinically-significant distress and impairment, or interference in a person’s life. For children, this typically involves their internal feelings (e.g., self esteem) as well as the impact on their home/family functioning, friendships/social functioning, and academic achievement.

Tic disorders include:

• Provisional tic disorder (the most common): the tics have happened for less than a year
• Chronic (sometimes called “persistent”) tic disorder (less common): tics have occurred for more than a year but are limited to either the motor or vocal domain
• Tourette’s disorder or syndrome (even less common): involves more than one motor tic and at least one vocal tic, for over a year

Functional Tic-Like Behaviors

Recently, a condition that mimics tics has become more common, especially during the COVID-19 pandemic. This condition is a type of functional neurological disorder (FND). In these cases, children and teens show behaviors that look like tics but are often more varied and complex, and can include self-harm or inappropriate vocal expressions. These behaviors usually begin around or after age 12, later than typical tic disorders, and may be influenced by exposure to similar behaviors on social media. If this sounds familiar, ask a doctor about Functional Neurological Disorder, as its treatment may differ from that of tic or Tourette’s disorders.

Tics can be diagnosed by a neurologist or by a mental health provider (e.g., psychologist, psychiatrist) who has training in this area.

Typically, diagnosis does not require any testing. Instead, providers will use observations (e.g., if the tics occur in session), interviews, and rating scales/questionnaires, such as the Yale Global Tic Severity Scale (YGTSS). 

When there is a behavior or movement that is not clearly a tic, it may be helpful to meet with an allergist, speech therapist, ophthalmologist, or other provider to rule out a concern in a different area of functioning. 

Since tics often worsen with attention, doctors may suggest a "watch and wait" approach if tics have been present for less than a year and are not causing major problems. If tics interfere with a child's life, treatment options include medication, therapy, or both.

Medications

Medications that sometimes help to decrease tics include haloperidol (Haldol), pimozide (Orap), and aripiprazole (Abilify), which are FDA-approved to treat tics. Other medications are sometimes used “off-label” (meaning they are not FDA-approved specifically for the treatment of tics), including guanfacine or clonidine. 

Therapy

The recommended therapy for tic and Tourette’s disorders is called Comprehensive Behavioral Intervention for Tics (CBIT). In this treatment, a doctor or therapist helps families identify when and where a child's tics happen, what triggers them, and what consequences may keep them going. The therapist then helps to suggest specific strategies to reduce the tics.

CBIT also includes Habit Reversal Training (HRT). Here, the therapist helps the child recognize warning signs before a tic starts and teaches them a competing response, which is a behavior that makes the tic harder to do. The child practices these responses and is rewarded for their efforts.

It is not uncommon for children with tics or Tourette’s to also have other psychological problems, such as ADHD, anxiety, or OCD. It can be helpful to treat these comorbid conditions with medication and/or therapy as well, which sometimes can help improve the tics. 

In many cases, tics become less severe after the teenage years. However, other conditions like ADHD, anxiety, OCD, and depression can continue into adulthood and cause problems.

Refer to the following resources for more information on tic disorders in children: 

Websites

• Tourette Association of America
  • Watch this video from Dr. John Walkup, Chair of Lurie Children's Department of Psychiatry & Behavioral Health, where he discusses how families can approach a new diagnosis of a tic disorder.
• Tichelper.com

Books

• Nix your Tics! Eliminate Unwanted Tic Symptoms: A How-To Guide for Young People by B. Duncan McKinlay, Ph.D., C.Psych