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.
Tyler’s “twitch” is usually called a “tic” by psychologists. Tics are defined 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
You might wonder what the difference between a tic and another concept – a compulsion is. Compulsions, which commonly happen when children and teens suffer from obsessive compulsive disorder, tend to be even more complex behaviours – eg lining things up, checking locks, tapping several times in certain places. Another difference between a tic and a compulsion is that 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 to know about tics.
- Tics in childhood and adolescence are not uncommon. Some studies say that up to 50% of children and teens will have some form of simple tic at some point in their childhood or adolescence (in my experience lip licking for example is very common).
- Many children’s tics go away completely as they get older, without any treatment. The most common time for tics to emerge are in the early primary school years – and they become much less common into adolescence. For other children and teens with tics – even if they don’t go away completely, they become much milder over time.
- Some children, teens and their families choose to not treat the tic. If the tic is not distressing the young person, nor interfering with their friendships, schooling or other areas of life – many families choose to ignore it.
However, it’s also important to know that for a small minority of children, tics can become longer lasting and problematic. A disorder called “Tourette’s Syndrome” is diagnosed with a child or adolescent has multiple tics which have lasted for more than a year, and cause problems or distress for the young person. A disorder called “Persistent Tic Disorder” is diagnosed when a child or adolescent has a single tic which has lasted more than a year and also causes problems or distress for the young person.
What should we do about tics if it is causing problems?
There is no single “right” thing to do if you have a child or teen with a tic. But here are some of the options.
First, it’s important to understand that the vast majority of children and teens with tics find it very hard to suppress the tic. It’s like trying to not scratch an itch. They can do it for a while but it can become very stressful – if they try to stop it for a long time. Sometimes this makes them more stressed - which often make the feeling of wanting to do the tic much 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 can come together as a team in coping with the tic, then often the outcomes are much better.
Second, some kids and teens response really well to learning “calm down” strategies for managing negative emotions such as stress, frustration or worry. For example, we can 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 appear to lessen during activities which require concentration, interest and challenge - but not high stress. This achieves something psychologists call "state of flow" and sometimes helping children and teen plan how to use these kinds of activities in stressful or "trigger" situations is very useful.
Third, for some young people, it can be helpful 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. This needs to be evaluated carefully, as for some young people, noticing (or having other people help them notice) their tic can make it worse. If a "noticing" process IS used, it’s really important to try not to let this process of helping the young person notice the tic make the child/teen 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. The noticing and recording period generally should be short and about information gathering - rather than a long term approach.
Fourth, helping the child or teen use a different, less obvious movement or sound to replace their tic can be helpful at times. This is sometimes called habit reversal treatment or habit replacement therapy and has good evidence associated with it. 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 isn’t a source of high stress which might then exacerbate the situation. For some children using habit reversal is exhausting and too intense so it needs to be done carefully - and sometimes needs a professional to monitor how it is going. 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.
If your child or teen has a tic you are concerned about, it can be helpful for you to visit your GP as a first step to get advice as to what to do next. This is important because very occasionally there are other neurological conditions which cause jerky movements or tics which may need to be ruled out. I have a brief worksheet on the Calm Kid Central site for children to start to think about their tics, if you are interested in this program please click below.
*Tyler is a composite of lots of children I’ve worked with over the years