12 year old Tyler* and his mum came to visit us concerned about something they called his “twitch”. To show me what they were talking about, they bought along an iphone video of Tyler playing his xbox while this twitch was happening. Basically Tyler’s “twitch” consisted of him tightening up one half of his face in a tight wink while swallowing hard at the same time. This had been increasingly happening to Tyler for several months. Now it would happen for hours at a time while playing his game, and also at times of stress at school. Tyler felt embarrassed about it, and his Mum felt worried for him – their GP had recommended they come and see us.
As you probably know, Tyler’s “twitch” is usually called a “tic”. Tics are defined in the DSMV as a “sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.” Tics can be simple – involving just one movement/noise – or complex – which are movements or vocalisations which involve a range of actions/noises.
Some examples of simple movement tics in children and teens are:
- Moving shoulders up and down
- Moving neck from side to side
- Blinking or winking eyes
- Moving mouth in a repeated way
- Touching the nose or face repeatedly
- Making obscence gestures
- Lip licking
Some examples of simple vocal tics in children and teens are:
- Making a grunting noise
- Sniffing/Coughing/Clearing the throat (in the absence of a cold)
- Growling/small screech
Some examples of complex movement tics in children and teens are:
- Moving an object (eg string/paper) around in a certain way
- Touching nose/then arms
- Following a pattern of movements
Some examples of complex vocal tics in children and teens are:
- Saying words or phrases out of context (in a sudden, recurrent way)
- Doing a series of coughs or grunts in a certain pattern
If you’ve worked with children /teens with anxiety you’ll have come across many with compulsions – and might wonder what the difference is between tics and compulsions. A rule of thumb is that compulsions tend to be more complex behaviours – eg lining things up, checking locks, tapping several times in certain places. In addition compulsions are usually done more deliberately and consciously – usually in the context of a child or teen trying to get rid of a certain thought or image (ie their obsessions). However the truth is that tics and compulsions are sometimes related, and some people believe them just to be the same spectrum of behaviours.
Tyler and his Mum talked to me about when his tic happened most commonly. As well as while playing xbox, it also happened when he was watching youtube, when he was stressed about a test at school and when he was frustrated or when he was really excited about something.
This is very common. In children and teens, tics are often triggered by two different types of situations. First they can be triggered by situations involving high levels of intense emotion – like excitement, stress, anger or fear/worry or fatigue. Second, they can be triggered by situations which involve mindless relaxation type tasks for example, sitting in the car, watching television or going to sleep.
Here are some other important facts I tell children and their families about tics.
- Tics in childhood in particular are not uncommon. Some studies say that 20 - 50% of children will have some form of simple tic at some point in their childhood (in my experience lip licking for example is very common). The most common age for tics to emerge is in early childhood.
- Most children’s tics go away completely within a year, without any treatment. Even for the small number of those for whom they don’t go away entirely, about 85% of children experience a lessening of their tics in adolescence. For your reference, the DSM calls this short lasting tic symptoms - “Provisional Tic Disorder”.
- However, it’s also important to know that for a small minority of children, tics can become longer lasting and problematic. The research is complicated and contradictory, but some studies have suggested this occurs in about 3% of children or teens who have reported tics at some point.
As you may know, “Tourette’s Syndrome” is diagnosed with a child or adolescent has multiple tics which have lasted for more than a year. A disorder called “Persistent Tic Disorder” is diagnosed when a child or adolescent has a single tic which has lasted more than a year.
Most children with persistent tic disorder or Tourette’s have at least one other diagnosis – most commonly ADHD, OCD and anxiety.
What should we do about tics if parents/carers ask us about them?
Some useful questions to ask parents/children if they are concerned about a tic are as follows:
- How long has it been happening for?
- What concerns you most about it?
- When does it happen?
- What have you tried?
- Are there any particular questions or worries you have about your tic?
- Is there anything good about it? (important info to get in terms of noticing the function/stress relieving nature of the tic)
I go on to talk with parents of kids/teens about these four concepts:
First, it’s important to understand that children and teens have little longer term control over the tic. They can often suppress it for a moment. However, they (especially older children) will often very strong urges to “do” the tic. If they continue to try hard to stop the tic, sometimes this makes them more stressed - which often makes the tic worse.
It’s therefore important to approach the tic as something which “happens to” the child or teen – rather than something they do on purpose. This means not getting angry at the child or teen or lecturing them about it. Instead, if a parent and child/teen/siblings can come together as a team in coping with the tic, then often the outcomes are much better. I also will usually talk with teachers/staff at the child’s school to help them understand the tic, and to assist them in helping other children know about the tic so they don’t tease/exclude etc.
Second, some kids and teens response really well to learning “calm down” strategies for managing negative emotions such as stress, frustration or worry. This is where we can talk with parents about brainstorm with and write down options for the young person so they have some ideas about what they can do when they are feeling overwhelmed. Options might include learning to relax their body, slow their breathing, relax their muscles, use calm sentences, asking for help, finding “busy” activities to distract themselves with. On this last point, tics often reduce when children/teens are in a "state of flow" doing activities which interest and challenge them. Helping young people identify these activities and plan to use them in triggering situations or when they are stressed is a really good way of helping them manage tics long term.
Third, it can be helpful for some young people to assist the child or teen simply become aware of their tic more often. Sometimes just helping young people notice when their tic occurs can help them reduce it happening as frequently. It should be noted that this is a strategy with some risks as for some young people the noticing can increase the tics. It's therefore usually important to do this only for a short period of time as a trial, and/or as an information gathering exercising. If this process is used, it’s also really important to try not to let this process of helping the young person notice the tic make the child/teen more stressed or upset. This can be tough, as often kids/teens DO get quite – understandably - upset when the tic is pointed out. For some children/teens we’ve come up with a neutral “code” that mum/dad can use to let them know the tics are happening – eg like a touch on the child/teens’ shoulder or getting their attention and the mum/dad touching their own shoulder. Some older kids/teens have found it works well to take charge of noticing the tic themselves – for instance have spent a week recording their tics – and the things that trigger their tics - on their phones for a week or so.
Fourth, I sometimes will use a more comprehensive approach where we use all of the above plus a habit reversal approach. The combination of all these areas above is sometimes called Comprehensive Behavioural Intervention for Tics – CBIT . A 2010 study found 52% of children who received CBIT showed significant symptom improvement compared to 18.5% receiving the control treatment over 6 months. As an overview, the habit reversal approach involves helping the child or teen use a different, less obvious movement or sound to replace their tic. This is the idea that instead of tic-ing, the child/teen will replace the tic with something similar to help relieve their stress – but something which causes less problems and is less noticeable. For example, the child/teen might “click” their tongue at the top of their mouth instead of putting their tongue outside their mouth, might squeeze their fingers together instead of touching their nose or might sigh softly instead of making a grunting noise.
Again, it is important to try to make sure habit replacement behaviours don’t become a source of high stress which might then exacerbate the situation. For some young people, doing habit reversal work is highly stressful and can again exacerbate the tics. It is important to monitor how it goes. Sometimes I’ve talked about this approach being “catch what you can” with families. This approach seems to reduce the pressure of having to do this every time.
Tyler and his Mum had a few sessions with me to do stress reduction strategies and habit reversal treatment. Although his tic didn’t go entirely, it reduced significantly and the last time I saw him he was feeling much more relaxed about it.
I hope this gives an overview of this area. As always, please consult/refer to a health professional if you are working with a child/teen with tic/s and need assistance. It should be noted that very rarely, children/teens with tics have a neurological condition which is causing the tics - and an evaluation is important to rule this out. If you would like to provide an article to parents/caregivers about this issue, please feel free to click on the link below and freely distribute.
I have also developed a brief one page activity sheet for children with tics to help them being to understand, monitor their tics for our Calm Kid Central members to use (professionals who work with children). If you are interested in this worksheet, please click below to find out about Calm Kid Central professional membership.