What Are Tics and Tourette's?

You’ve probably seen a tic without even realizing it: A blink that happens just a bit too often, a shrug that seems out of place, a small constant cough. Tics are common in children and they often seem to come out of nowhere.

When a child develops a tic it can be scary for parents, who find themselves wondering if the little coughs or blinks will ever go away or worrying that they could be a sign of something more serious. The good news is that most tics go away on their own, and don’t come back. If you think your child has developed a tic, experts recommend seeing a pediatrician to confirm that what you’re seeing is, indeed, a tic. But in most cases the recommendation will be for parents to simply watch and wait before any further intervention is considered. It’s only when tics become chronic and impairing that treatment is needed.

“Tics are basically a signal from the brain that sends an urge for a movement or a sound,” explains Wendy Nash, MD, a child and adolescent psychiatrist. Tics are repetitive, rapid movements or sounds. Most are what’s called “simple” tics, meaning tics that are one movement like a squint or a quick nod of the head. Some, called “complex” tics, are larger combinations of movements or sounds, for example reaching up and shaking your head, or a blink followed by throat clearing.

Some common simple tics include:

• Shoulder shrugging
• Eye blinking
• Lip biting
• Facial grimacing

• Clearing the throat
• Humming, sniffing, snorting, or squealing
• Repeating words

The movements and sounds are considered to be what Dr. Nash calls un-voluntary. “They’re not quite voluntary and not quite involuntary because with the right training they can be suppressed,” she explains. Kids may describe feeling what’s called a “premonitory urge” before a tic, which is an uncomfortable sensation that drives, and is relieved by, the tic. Tics can occur at any age — plenty of grown-ups have them, too — but they most commonly emerge during childhood or early adolescence.

“The short answer is that we don’t know fully what causes tics,” says Dr. Nash. “There’s some evidence to suggest that tics are hereditary, which is to say that if a parent has a tic a child is more likely to have one as well. But they can also be environmental.” Environmental triggers include poor sleep, sickness, and stress.

There are three kinds of tic disorders:

Provisional tic disorder: Formerly called “transient tic disorder,” this is the diagnosis most children will receive if they have a simple motor or vocal tic that’s lasted less than a year. It is not yet clear if the tics will evolve into a more serious tic disorder or resolve without assistance. Children with provisional tic disorder often stop having tics on their own.

Chronic motor or vocal tic disorder: To be diagnosed with a chronic tic disorder a child’s tics must be persistent for over a year without going away for any prolonged period time. Kids who have a chronic tic disorder usually need clinical intervention.

Tourette’s syndrome (also known as Tourette’s disorder): Tourette’s is probably the best-known tic disorder, thanks to wide portrayal in the media, but it is not the most common. For a diagnosis of Tourette’s syndrome, a child must exhibit both motor tics and vocal tics for more than a year and be under the age of 18. A very small percentage of children have what’s called coprolalia, which involves involuntary cursing or making socially inappropriate remarks. “Most people with Tourette’s syndrome also have other symptoms as well,” says Dr. Nash. Other disorders include OCD, an anxiety disorder, ADHD, or autism spectrum disorder.

Parents who are concerned that a child may have a tic disorder should begin by visiting their pediatrician. The pediatrician can then determine if more help is needed and offer a referral to a neurologist or a psychiatrist. These doctors will want to rule out other possible issues that could be causing the tics, including:

• A seizure disorder
• A condition called PANS or PANDAS that causes acute-onset obsessive-compulsive disorder (OCD)
• Other neurological or movement disorders

The initial realization that a child has a tic can be disturbing. But Dr. Nash suggests that once other medical diagnoses are ruled out, parents wait and watch instead of seeking treatment right away — unless the tics are socially or functionally impairing. “Parents are often more distressed by a child’s tics than the child is,” she notes. “If a child has a mild tic that isn’t bothering them, we usually encourage parents to wait and see if it resolves on its own.”

Kids may not even be aware that their tics are anything out of the ordinary unless someone else draws attention to them. “Teasing, bullying, or embarrassment are often the biggest motivators for kids when it comes to seeking treatment,” says Dr. Nash.

Parental anxiety about tics can backfire by making them worse. By drawing attention to a tic that a child isn’t worrying about, parents can inadvertently make them feel self-conscious and concerned, which in turn can exacerbate the tic. “The best thing you can do for your child is to stay calm and avoid drawing attention to the tic,” she explains. “Managing your own anxiety is a big part of helping your child, and yourself.”

That said, Dr. Nash recommends parents seek treatment if:

• Tics have been present for over a year, or are becoming more severe
• Tics are causing social problems or have become upsetting to your child

The treatment of choice for tic disorders is a form of cognitive behavioral therapy called habit reversal therapy (HRT). The goal of HRT is to help kids develop a kind of early warning defense system to help them counteract the tics before they occur.

During HRT a therapist works with a child to help them learn to recognize the premonitory urge that precipitates tics and become aware of situations that may trigger them. Then they develop a “competing” response — an action the child can perform instead of the tic that would be less noticeable to others. For example, a child who clears their throat repeatedly might try taking a deep breath instead. Some kids, Dr. Nash says, may be practicing a version of this when they try to turn attention-drawing tics into something that seems more natural — for example, turning a grimace into a yawn, or a hand flip into what looks like a stretch.

As part of HRT children may also be taught relaxation techniques like breathing or mindfulness exercises that can help decrease the frequency of their tics.

Habit reversal therapy is often effective on its own but in some cases your child’s doctor may suggest combining it with medication. Medication options for tics and tic disorders vary widely, depending on the severity of the tics and other disorders a child may have. Some medications for other disorders, such as ADHD, are suspected of triggering or exacerbating tics. But, says Dr. Nash, the evidence is unclear as to whether medications can either improve or worsen tics because of their cyclical nature.

The same is true for habit reversal therapy, Dr. Nash explains. “Because tics get better on their own it can be hard to tell if the therapy alone is responsible for improvement or if a child has improved on their own.” But the therapy can benefit kids in either case, she notes: “Learning the techniques helps kids feel more confident and in control, which can have a powerful impact.”