Tic Disorder and Tourette Syndrome

What is a tic?

A tic is an involuntary, rapidly occurring, repetitive movement. Some children like to refer to tics by other names such as “habits”, “actions” or “sounds”. These descriptions are beneficial for a child as using their own language to describe their tics helps them to make sense of their experience. Many children experience a tension or sensation (e.g., tingling, itchiness) in their body or a specific muscle group just prior to the tic occurrence. Doing the tic provides relief from this tension or sensation.

Tics that involve actions or muscle movement are called motor tics, while those that involve sounds or vocalisations are called vocal tics. Examples of common motor and vocal tics are provided below. Tics can also be classified based on their complexity. Simple tics are those that involve a single muscle group or brief sound, while complex tics are those that involve multiple muscle groups, meaningful words, or a combination of motor and vocal tics.

Examples of common tics

Motor tics

  • Eye blinking
  • Facial grimacing
  • Nose wrinkling
  • Kicking
  • Touching objects
  • Shoulder shrugging
  • Neck jerking
  • Leg shaking

Vocal tics

  • Coughing
  • Grunting
  • Sniffing
  • Snorting
  • Throat clearing
  • Saying a word or phrase

For many people, the first examples that come to mind when thinking of tics are uttering obscene or unacceptable words (coprolalia) and completing sexual or obscene gestures (copropraxia). Although these examples are well-known due to their frequent representation in the media, they are actually relatively uncommon.

What is Tourette Syndrome?

Tourette Syndrome is one type of tic disorder. Diagnoses for tics disorders are made based on the length of time that tics have been present and the type of tics that a child presents with. Possible tic disorder diagnoses are summarised below.

Provisional tic disorder: first occurrence of tics was < 12 months ago

Persistent or Chronic tic disorder: only motor OR vocal tics are present (i.e., not both), first occurrence of tics was > 12 months ago

Tourette Syndrome: BOTH motor and vocal tics are present, first occurrence of tics was > 12 months ago

Will my child always have tics?

Tics are a common occurrence in childhood with up to 18% of school aged children experiencing tics. Some tics resolve spontaneously and do not require any treatment while other tics have a variable (i.e., type of tics changes but tics always present) or chronic (i.e., same tic always present) presentation. Children usually first start to experience tics around age 6 or 7 with a high percentage (up to 65%) of individuals reporting that tics resolved or remained present in only a mild form by adulthood.

What causes tics?

At this stage no one knows exactly what causes tics. The most common theory is that tics have a neurological basis (i.e., they are a result of specific brain activity). Although internal factors (such as thoughts and feelings) and external environmental factors do not cause tics they have been shown to influence tic severity and frequency. For example, tics are often worse during times of increased stress, worry or excitement and can be exacerbated during some everyday activities such as while playing sports, using the computer or completing school work. Although many simple tics may resolve spontaneously (and so don’t require treatment) chronic tics can have a significant impact on a child’s self-esteem, can reduce participation in their social environment and can be quite distressing for parents.

But if tics have a neurological basis how can therapy help?

As noted above, although tics have a neurological basis internal (e.g., thoughts and feelings) and external (e.g., events, others responses) environmental factors have been shown to influence tic frequency and severity. A behavioural model of tics that proposes various pathways through which tics are reinforced can be used to guide treatment approaches. These approaches can assist children to develop confidence in their ability to cope with tics effectively when they occur.

Therapy can assist your child in a number of ways, including

  • teaching strategies to manage tics more effectively
  • reducing the impact of tics on the child and family
  • educating your child, family, peers and school about tics
  • making environmental adjustments to reduce intensity and impact of tics
  • improve self esteem
  • manage co-occurring conditions such as ADHD, OCD or anxiety

Therapy can also assist parents to:

  • understand the difference between tics and other behaviour
  • understand helpful and unhelpful responses to tics
  • provide helpful support to their child
  • address concerns about the long term impact of tics on your child

What does therapy for tics involve?

Although there is no “cure” for tic disorders, Comprehensive Behavioural Intervention for Tics (CBIT) has been shown to be an effective behavioural intervention, resulting in a greater reduction in tic severity than supportive counselling and education. One large recent research study reported that over half the children who received this intervention were much improved or very much improved (Piacentini et al., 2010).

CBIT involves the following components:

Education: Receiving a diagnosis of tic disorder can evoke various emotions for parents, caregivers and children and give rise to many worries about the child’s future. Learning about tics is an important component of treatment for both parents and children, as it can help to alleviate worries and to provide guidance about appropriate responses and support.

Environmental Modifications: As noted above various environmental factors can influence tic presentation. An analysis of the potential impact of environmental factors is undertaken and a problem solving approach is used to work out practical adaptations to environmental triggers where appropriate.

Awareness Training: This involves teaching the child to become aware of the occurrence of the tic, including any urges preceding the tic and how the tic starts and progresses. This component is essential prior to implementing competing response training.

Competing Response Training: The child is taught a competing response (CR; a behaviour that is physically incompatible with the tic), and practices implementing this response whenever the urge or tic occurs. For example, if the tic involves the heel coming off the ground and the leg shaking the CR might involve pushing the heel into the ground. An alternative to competing response training involves the child learning to do a replacement behaviour that is similar to the tic (so that the urge is still satisfied) but that causes less distress. For example, for a tic that involves violent neck movements a replacement behaviour might involve moving the neck purposefully in slow motion.

Social Support: Parental support (and sometimes teacher support) is important in helping the child to be consistent in applying the new strategies that they have learnt. The support person might assist the child to notice the tic if it occurs and gently remind them to implement the agreed upon response. The support person may also provide praise and/or other rewards to increase the child’s motivation to use the substitute behaviour.

Children with tic disorders often experience a number of co-occurring difficulties including anxiety, low self-esteem, low mood, shame, self-consciousness, attention difficulties and obsessive compulsive symptoms. Cognitive Behavioural Therapy can be used to address these additional difficulties, which often provide a greater source of distress than the tics, and can contribute adversely to tic severity.

A psychologist who is experienced in working with children with tics will be able to determine which approach will be the most appropriate and beneficial for your child. For example, some children benefit by a focus on education, environmental modification and treatment of co-occurring conditions while others gain more benefit from addressing the tics directly. They will also be able to provide some guidance on whether medication is an appropriate treatment option and will be able to provide some referral options to paediatricians or child psychiatrists if appropriate.

How do I make an appointment or access more information about tics?

If you would like to find out more information about tic disorders and their treatment or would like to book an appointment please contact us on 02 8814 5703 or reception@talbotpsychology.com.au

You can also get more information about tic disorders from the Tourette Syndrome Association of Australia and Tourette Syndrome Plus website.

Tic Disorder and Tourette Syndrome

What is a tic?

A tic is an involuntary, rapidly occurring, repetitive movement. Some children like to refer to tics by other names such as “habits”, “actions” or “sounds”. These descriptions are beneficial for a child as using their own language to describe their tics helps them to make sense of their experience. Many children experience a tension or sensation (e.g., tingling, itchiness) in their body or a specific muscle group just prior to the tic occurrence. Doing the tic provides relief from this tension or sensation.

Tics that involve actions or muscle movement are called motor tics, while those that involve sounds or vocalisations are called vocal tics. Examples of common motor and vocal tics are provided below. Tics can also be classified based on their complexity. Simple tics are those that involve a single muscle group or brief sound, while complex tics are those that involve multiple muscle groups, meaningful words, or a combination of motor and vocal tics.

Examples of common tics

Motor tics

  • Eye blinking
  • Facial grimacing
  • Nose wrinkling
  • Kicking
  • Touching objects
  • Shoulder shrugging
  • Neck jerking
  • Leg shaking

Vocal tics

  • Coughing
  • Grunting
  • Sniffing
  • Snorting
  • Throat clearing
  • Saying a word or phrase

For many people, the first examples that come to mind when thinking of tics are uttering obscene or unacceptable words (coprolalia) and completing sexual or obscene gestures (copropraxia). Although these examples are well-known due to their frequent representation in the media, they are actually relatively uncommon.

What is Tourette Syndrome?

Tourette Syndrome is one type of tic disorder. Diagnoses for tics disorders are made based on the length of time that tics have been present and the type of tics that a child presents with. Possible tic disorder diagnoses are summarised below.

Provisional tic disorder: first occurrence of tics was < 12 months ago

Persistent or Chronic tic disorder: only motor OR vocal tics are present (i.e., not both), first occurrence of tics was > 12 months ago

Tourette Syndrome: BOTH motor and vocal tics are present, first occurrence of tics was > 12 months ago

Will my child always have tics?

Tics are a common occurrence in childhood with up to 18% of school aged children experiencing tics. Some tics resolve spontaneously and do not require any treatment while other tics have a variable (i.e., type of tics changes but tics always present) or chronic (i.e., same tic always present) presentation. Children usually first start to experience tics around age 6 or 7 with a high percentage (up to 65%) of individuals reporting that tics resolved or remained present in only a mild form by adulthood.

What causes tics?

At this stage no one knows exactly what causes tics. The most common theory is that tics have a neurological basis (i.e., they are a result of specific brain activity). Although internal factors (such as thoughts and feelings) and external environmental factors do not cause tics they have been shown to influence tic severity and frequency. For example, tics are often worse during times of increased stress, worry or excitement and can be exacerbated during some everyday activities such as while playing sports, using the computer or completing school work. Although many simple tics may resolve spontaneously (and so don’t require treatment) chronic tics can have a significant impact on a child’s self-esteem, can reduce participation in their social environment and can be quite distressing for parents.

But if tics have a neurological basis how can therapy help?

As noted above, although tics have a neurological basis internal (e.g., thoughts and feelings) and external (e.g., events, others responses) environmental factors have been shown to influence tic frequency and severity. A behavioural model of tics that proposes various pathways through which tics are reinforced can be used to guide treatment approaches. These approaches can assist children to develop confidence in their ability to cope with tics effectively when they occur.

Therapy can assist your child in a number of ways, including

  • teaching strategies to manage tics more effectively
  • reducing the impact of tics on the child and family
  • educating your child, family, peers and school about tics
  • making environmental adjustments to reduce intensity and impact of tics
  • improve self esteem
  • manage co-occurring conditions such as ADHD, OCD or anxiety

Therapy can also assist parents to:

  • understand the difference between tics and other behaviour
  • understand helpful and unhelpful responses to tics
  • provide helpful support to their child
  • address concerns about the long term impact of tics on your child

What does therapy for tics involve?

Although there is no “cure” for tic disorders, Comprehensive Behavioural Intervention for Tics (CBIT) has been shown to be an effective behavioural intervention, resulting in a greater reduction in tic severity than supportive counselling and education. One large recent research study reported that over half the children who received this intervention were much improved or very much improved (Piacentini et al., 2010).

CBIT involves the following components:

Education: Receiving a diagnosis of tic disorder can evoke various emotions for parents, caregivers and children and give rise to many worries about the child’s future. Learning about tics is an important component of treatment for both parents and children, as it can help to alleviate worries and to provide guidance about appropriate responses and support.

Environmental Modifications: As noted above various environmental factors can influence tic presentation. An analysis of the potential impact of environmental factors is undertaken and a problem solving approach is used to work out practical adaptations to environmental triggers where appropriate.

Awareness Training: This involves teaching the child to become aware of the occurrence of the tic, including any urges preceding the tic and how the tic starts and progresses. This component is essential prior to implementing competing response training.

Competing Response Training: The child is taught a competing response (CR; a behaviour that is physically incompatible with the tic), and practices implementing this response whenever the urge or tic occurs. For example, if the tic involves the heel coming off the ground and the leg shaking the CR might involve pushing the heel into the ground. An alternative to competing response training involves the child learning to do a replacement behaviour that is similar to the tic (so that the urge is still satisfied) but that causes less distress. For example, for a tic that involves violent neck movements a replacement behaviour might involve moving the neck purposefully in slow motion.

Social Support: Parental support (and sometimes teacher support) is important in helping the child to be consistent in applying the new strategies that they have learnt. The support person might assist the child to notice the tic if it occurs and gently remind them to implement the agreed upon response. The support person may also provide praise and/or other rewards to increase the child’s motivation to use the substitute behaviour.

Children with tic disorders often experience a number of co-occurring difficulties including anxiety, low self-esteem, low mood, shame, self-consciousness, attention difficulties and obsessive compulsive symptoms. Cognitive Behavioural Therapy can be used to address these additional difficulties, which often provide a greater source of distress than the tics, and can contribute adversely to tic severity.

A psychologist who is experienced in working with children with tics will be able to determine which approach will be the most appropriate and beneficial for your child. For example, some children benefit by a focus on education, environmental modification and treatment of co-occurring conditions while others gain more benefit from addressing the tics directly. They will also be able to provide some guidance on whether medication is an appropriate treatment option and will be able to provide some referral options to paediatricians or child psychiatrists if appropriate.

How do I make an appointment or access more information about tics?

If you would like to find out more information about tic disorders and their treatment or would like to book an appointment please contact us on 02 8814 5703 or reception@talbotpsychology.com.au

You can also get more information about tic disorders from the Tourette Syndrome Association of Australia and Tourette Syndrome Plus website.