A Clinician’s Guide to Tic Disorders in Children: Symptoms, Comorbidities & Treatments

Persistent tic disorders, including Tourette’s disorder, affect about one in fifty children in the U.S. according to the latest research – more children than previously thought, and a figure that carries important implications for clinicians.¹ What’s more, tic disorders are highly comorbid. More than 80% of children with Tourette’s disorder have a co-occurring mental, behavioral, or developmental disorder, with attention deficit hyperactivity disorder (ADHD) and anxiety topping the list of commonly diagnosed conditions.²

These facts and figures suggest that clinicians are more likely than not to encounter tic disorders when caring for pediatric patients. While tics improve over time for many children (some even experience remission), they can be severely distressing and lead to problems in school and to other functional impairments. Beyond understanding tic disorders, clinicians must be aware of the related conditions and factors that can aggravate tics, as well as current evidence-based guidelines for treating the neurological condition.

What Are Tics?

Tics are sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations that can be simple or complex in nature.³ Tics commonly involve the head and upper body, and occur many times a day, nearly every day.

Motor and Vocal Tics

Simple motor and vocal tics comprise sudden, brief, meaningless movements, sounds, or noises. They include but are not limited to the following:

• eye movements (like rapid blinking)
• mouth movements (twitching, grimacing)
• head jerks
• throat clearing and grunting

[Could Your Child Have a Tic Disorder? Take This Self-Test]

Complex motor and vocal tics tend to be slower and longer. These movements, sounds, and utterances appear purposeful to others. They include but are not limited to the following behaviors:

• facial gestures
• touching objects or self
• abnormal postures and muscle tensing
• copropraxia (making obscene gestures)
• coprolalia (using obscene language)
• palilalia and echolalia (echoing the self and others, respectively)

Tics are considered involuntary movements, though they can be briefly suppressed. Premonitory urges, or underlying, unpleasant sensations – like an itch, tingle, or pressure of some kind in a part of the body – generally precede tics. Engaging or expressing the tic typically relieves the sensation.

Tic Disorders

Tics are divided into distinct diagnostic categories in the DSM-5. Patients must have experienced symptoms before age 18 to merit a diagnosis for any of the following tic disorders.

[Read: What a Chronic Tic Disorder Looks Like]

• Tourette’s disorder, also known as Tourette syndrome, comprises multiple motor tics and at least one vocal tic that have persisted for more than one year. Motor and vocal tics do not have to be present concurrently, and they may wax and wane in frequency. As many as half of children with Tourette’s disorder are thought to go undiagnosed.⁴
• Persistent (chronic) motor or vocal tic disorder includes motor- or vocal-only tics (single or multiple) that have persisted for more than a year.
• Provisional tic disorder is when children exhibit motor and/or vocal tics for less than a year. Temporary tics are quite common in childhood, with as many as 20% of school-age children experiencing them at one point.⁵

Functional Tic-Like Behaviors

Since the start of the pandemic, rates of tic-like behaviors, especially in young girls, have skyrocketed, concerning pediatricians and families alike. From a teen onset and lack of premonitory sensations to dramatic, expressive tics, these behaviors differ from symptoms outlined for tic disorders in the DSM-5, and they do not respond to typical tic treatments.

Researchers believe that the rise of functional tic-like behaviors may be partially linked to popular videos on social media of youth displaying tics or tic-like behaviors.⁶ Many patients, according to clinicians, present with functional tic-like behaviors that resemble those shown in these videos.⁶ This explains their nickname: ‘TikTok tics.’ Psychosocial stressors, loneliness, and social distancing, as well as pre-existing conditions, like anxiety and depression, may also predispose teens to these behaviors.⁶ Some researchers even refer to the phenomenon as a “mass sociogenic illness.”⁷

Tics: Development & Additional Features

Most Tics Follow a Similar Trajectory

Tics typically change anatomic location, frequency, type, complexity, and severity over time. Tics almost always start in the face and head in early childhood before progressing down the body. Facial tics typically appear first at around age 5 and 6. Vocal tics generally have a later onset, often appearing between the ages of 8 and 12.

Tics tend to peak in severity at around the start of puberty, and they decrease in severity in mid-adolescence. Up to two-thirds of children see a substantial decrease or complete remission of their tics by early adulthood.⁸

Though tic disorders are more common in boys than in girls,² tics sometimes can be more severe in girls.

Tics Frequently Co-occur with Other Conditions

About 83% of children with Tourette’s disorder have at least one additional mental, behavioral, or developmental condition like the following:²

• Anxiety (61%)
• ADHD (52%)
• Learning disabilities (34%)
• Autism (21%)

In addition, about one-third of people with Tourette’s disorder have co-occurring ADHD and obsessive-compulsive disorder (OCD).⁹ Often, comorbid conditions negatively impact quality of life, including school performance and interpersonal relationships, in children more than do tics alone.^{10, 11}

Sleep problems are common in children with Tourette’s disorder.¹² Many children with tics also experience episodes of aggression, or “rage attacks,” that appear to be related to tic severity.¹³

Environmental Factors Influence Tics

Tics are not learned behaviors, but they are sensitive to environmental factors. Antecedents, or triggers, to tics include the following, as endorsed by parents of children with tic disorders:¹⁴

• Places and situations. About 78% of parents say the school classroom and public places worsen their child’s tics.
• Activities. Television and video games greatly exacerbate tics in children, according to 92% of parents. Getting home from school and doing homework are also commonly reported tic antecedents.
• Other people. About 14% of parents say their child’s tics worsened in the presence of a specific person.
• Internal experiences. Anger, frustration, and other negative emotions appear to trigger tics more than do positive emotions like excitement (16% vs. 10%, respectively).

Relieving premonitory urges reinforces tics. But tics are also subject to positive and negative external reinforcers. About 35% of parents say their child’s tics are worsened when others laugh, look at, or ask about the tics. Perhaps the strongest tic reinforcer for children, according to 72% of parents, is telling them to stop “ticcing.” Each of these situations tends to make the child more self-conscious and anxious about their tics leading to a worsening of the premonitory urge.

In addition, tics are negatively reinforced if a child is allowed to leave an aversive setting or activity, like homework or chores, because of their tics. Making something bad go away is similar in function to receiving a reward.

Tics Affect School and Learning

Though impairment is not part of diagnostic criteria for tic disorders, tics – and stigma surrounding them – contribute to issues in school and with socializing.

• Depending on severity, tics can interfere with reading, test taking, paying attention in class, and participation in extracurriculars like sports and social clubs.
• About half of children with Tourette’s disorder experience bullying.² Some children may try to camouflage or cope with their tics by adopting a class clown persona or disrupting the classroom in other ways.
• Normal school-related stressors – like tests and important assignments – can worsen tics and create a reinforcing cycle. It’s the same for anxious children who worry about controlling tics in school, especially if they have coprolalia. Co-occurring conditions may also compound learning challenges.

Some students with tics may be removed from the classroom or otherwise disciplined for their tics, which is devastating for their educational experience. It’s especially problematic when we consider that Black and Hispanic children are disproportionately disciplined in schools. What’s more, though children from all racial and ethnic groups or socio-economic backgrounds experience similar rates of Tourette’s disorder, white children are still more likely to receive a diagnosis than are Black and Hispanic children.¹⁵

Tic Disorders Treatments

If tics do not affect a patient’s daily life, the American Academy of Neurology recommends watchful waiting, as tics improve with time for many patients.¹⁶ It also recommends that clinicians inform patients and their caregivers about the typical progression and trajectory of tics. Clinicians should also screen for ADHD, anxiety, OCD, and other related conditions in patients with tics.

Comprehensive Behavioral Intervention for Tics

Because tics are so sensitive to and affected by environmental influences, behavior therapy is considered first-line treatment for tic disorders if symptoms cause functional impairment in patients. Behavior therapy works to eliminate or reduce the influences that aggravate tics.

Comprehensive behavioral intervention for tics (CBIT) is a multicomponent treatment comprising the following elements:

• Habit Reversal Training (HRT) focuses on the urge-tic relationship. Children learn to become aware of premonitory urges and to immediately engage in a competing, physically incompatible response to dissipate the urge, ultimately reducing or breaking the tic-relief connection. A child who feels a snorting tic come on while breathing in through their nose, for example, would breathe in through their mouth and exhale through the nose as a competing response. (You can’t snort while exhaling.) The child would engage in the competing response for at least a minute, or until the urge dissipates.
• Function-based Interventions address external tic triggers and reinforcers. Parents will learn to avoid responding to tics as they happen (whether the response is “good” or “bad”) and other strategies. If starting on homework aggravates tics in a patient, for example, after-school down time can help them smoothly transition to the activity and reduce tic severity. Scheduled homework breaks, in addition, work well to break the tic-escape connection if a child has long been allowed to leave the task because of their tics. Approaches will depend on the patient, but the goal of this treatment is to create a tic-neutral environment. The overall idea is to eliminate any reinforcement, positive or negative, related to tics.

Medication and Medical Treatments for Tic Disorders

The following interventions are commonly prescribed to treat tic disorders:

• Alpha-2 agonists. Guanfacine and clonidine reduce tic severity in children with tic disorders alone, and they are known to reduce tic severity and improve ADHD symptoms in those with tics and ADHD. They are associated with mild side effects.
• Neuroleptics (aripiprazole, risperidone, pimozide) are sometimes used, though they are associated with significant side effects. Clinicians should prescribe these medications if benefits outweigh risks, and closely monitor patients.
• Botulinum toxin (Botox injections) may help reduce facial tics in adolescent patients.

Tourette Syndrome and Tic Disorders: Next Steps

• Overview: What Is a Tic Disorder?
• Self-Test: Tic Disorders in Children
• Read: What’s the Truth About Tic Disorders?

The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Current Guidelines for Treatment and Behavioral Interventions for Tourette Syndrome and Tic Disorders” [Video Replay & Podcast #422], with John Piacentini, Ph.D., ABPP, which was broadcast on September 22, 2022.

The Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude

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