Tic Tic Tic

One of the many puzzling aspects of childhood, occurring in some 20% of healthy children, is the nervous tic. Frequently defined as a sudden, repetitive, involuntary movement or vocalization, tics can include a wide range of actions. Susan Scheftel, PhD, an assistant clinical professor of medical psychology in psychology at the Columbia Psychoanalytic Institute for Training and Research, writes that tics are most often seen, “near the head and shoulders and in some way partake of the five senses: they eyes blink and roll; the eyebrows elevate; the nose wrinkles and sniffs; the hands touch, tap or align; the lips purse and twitch; the tongue protrudes or licks and the mouth makes all manner of sounds that the ears can hear.”  Other tic variations include throat clearing, grimacing and shoulder shrugging. Tics are seen more commonly in boys than girls, and they carry a genetic aspect, with a tendency to run in families. Tics can be simple, comprising one movement such as a blink, or complex, involving a muscle group, such as a grimace. And yet, as common as they are, they can be perturbing to parents and caregivers, teachers, and peers of the child who is exhibiting the tic. This post stems out of a conversation between Anouck and I where we discussed childhood tics and how to best support the child who is “ticcing.” 

Anouck:  Thanks so much for being willing to talk to our Marshmallow Peeps about childhood tics. When I told my ETM co-pilot Maki that we’d be discussing childhood tics she said, “Argh! Where was this conversation 5 years ago when my son was in first grade. He would eat his pencils in class and it drove the teacher crazy, and so in turn it drove me crazy. Luckily, he out grew it.” I’m hoping our conversation, though clearly too late for Maki, will illuminate how best to handle childhood tics. 

I’ll kick off the discussion on a personal note. My daughter, when she was around 4 years old had a small verbal tic (where she’d click her tongue before she spoke). It came and went, but once I took note of the tic’s presence, it was very triggering to me as a parent– even more so when it went away only to later resurface! I found it frustrating, and in turn, found it difficult to mask that frustration. But I didn’t want to show her that I was frustrated with her behavior for fear of making her verbal tic worse. Any advice for parents who, in witnessing our children’s tics, start to get twitchy?

Vinay: Alarming as it might be upon discovering that your child has developed a tic, the first thing to do is take a deep breath to keep from panicking! As concerned as you may feel, try to imagine how your child is feeling to be having this strange, involuntary behavior to contend with– which is actually not exactly involuntary, but I’ll talk more about that in a bit. I want to first address the parental response to the child’s tic. When we parents become worried, we inadvertently pass this onto our child, exacerbating their own stress and possibly driving the “ticcy” behavior even more. Dr. Wendy Nash, a child and adolescent psychiatrist at the Child Mind Institute in New York, cautions about parental anxiety around tics. She states that parental anxiety, “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.”

A: Exactly! So what do we parents and caregivers do?

V: Well, instead of panicking or making the child feel self-conscious about the tic, I’d recommend finding a trusted adult to talk to about your feelings of worry out of earshot of your child, and do your level best to maintain calm, open-hearted energy in the presence of your child. Observe, and note the frequency of the tics, and the circumstances under which the tics most often occur to see if a pattern emerges. If your child is older, and sufficiently bothered by the tic itself, have them also participate in this investigation-of-sorts, to shift to a more curious mindset. They can help themselves by bringing an awareness to the tic. I want to go back to what I said before about a tic being “involuntary.” Dr. Nash specifically chooses not to use the word when referring to tics. She prefers the term, unvoluntary“They’re not quite voluntary and not quite involuntary because with the right training they can be suppressed.”

I would recommend meeting with your child’s pediatrician to confirm that a tic is really what you are observing, and that it isn’t something more serious, such as a seizure, or a condition known as PANDAS, which the National Institute for Mental Health describes as, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. A child may be diagnosed with PANDAS when: Obsessive-compulsive disorder (OCD), tic disorder, or both suddenly appear following a streptococcal (strep) infection, such as strep throat or scarlet fever.”

Other professionals acknowledged that tics can occur concurrently with other disorders, such as Attention-Deficit/Hyperactivity Disorder, Obsessive-Compulsive Disorder, and Anxiety; in this case, the onset of tics, especially those that continue to show up in one form or another for over a year, may indicate that one of these conditions is present or may potentially emerge.

A: Okay, so once the parent rules out that it is not something more serious or debilitating, what would be the next step?

V: As to whether or not to seek treatment, I discovered one theme among professionals as I searched for next steps in the available literature. They urged parents to assess just how much the tics bothered their child. They recommended to seek treatment only if the tics were causing distress or impeding functionality for the child. 

But, most parents I’ve met are seldom satisfied with a wait-and-see approach when it comes to their kids, so if energy is going to be spent doing something, I’d recommend some skill building to address the feeling of anxiety, or the tendency to worry. Here are some ideas to guide your child towards addressing their nervousness or anxiety in general: 

  • belly breathing: have your child sit or lie comfortably and take a deep breath in, so that their belly goes out as far as it can. Ask them to exhale, watching their belly go back in, and repeat the process as many times as needed for the child to be comfortable. For younger kids it may be helpful to have a visual prompt, such as a small stuffed animal “riding the waves” of their bellies. Instruct them to take 10 belly breaths (inhalation-exhalation = one breath) whenever they notice themselves feeling even a little anxious.
  • breathing visualization: invite them to share with you which color they associate with worry, and which they associate with calm and relaxation. Ask them to imagine their body is full of the “worried” color, and they have to breathe out the worried color to be able to breathe in the calm color. Every inhalation takes in the calm color and every exhalation releases the worried color, such that calm replaces worry over a series of breaths. 
  • progressive muscle relaxation: have your child sit or lie in a comfortable space and close their eyes. Have them begin by taking a few deep belly breaths and then invite them to focus on each part of their body, starting with their toes and going up to their faces. Ask them to squeeze the muscles in this body part for a few seconds and then release the muscles, exhaling as they do so. Once they have done this exercise consistently over a few days, they can practice squeezing and releasing their fists, their leg muscles and their facial muscles whenever they notice themselves feeling anxious, to help them experience the difference between tension and sweet relaxation.

A: So this is a great place to work from in order to help children let go of their tension and find some mindful relaxation, but do you have any advice for bringing awareness to your child so they might be able to stem the need for the tic to present itself?

V: Given that oftentimes, the tic is transitory, and usually quite harmless, and tends to bother parents far more than it bothers the child experiencing the tic, I would recommend finding acceptance and taking measures to give you as the caregiver, a break, perhaps taking a walk or at least going into a different space if seeing the tic is triggering. Some self-care, and compassionate support from loved ones can help with managing our own feelings about our child having a tic, without exposing our kids to the weight of our emotional baggage around it. If we ourselves experienced tics or some other difference, and were teased at school, or treated with less than a compassionate approach at home, we may well find ourselves feeling stressed and struggling to offer this same space and compassion to our child in the face of a tic, but this is certainly our own work to do. If talking to loved ones does not bring about desired relief, a counselor may help explore the sources of your triggers and help you dismantle them. 

With about 20% of kids experiencing tics, and many concerned parents, a lot of anecdotal information has been collected to help give shape to the story of tics. Tics tend to come and go, and may change form from one kind of tic, perhaps blinking the eyes, to another, such as twitching the nose. In most children these tics are gone within the year, and do not return. For those tics that become severe, or persist beyond a year without any significant length of time between ticcing episodes, a closer look is certainly warranted. 

Now, for tics that are bothersome to children, where they feel different and are being teased at school, being able to guide them to try and suppress the tic can be life-changing in terms of their social experiences. Dr. Nash describes Habit Reversal Therapy as the treatment of choice: 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.”

In the course of Habit Reversal Therapy (HRT) children are taught to tune into the premonitory urge that is experienced before the tic, an uncomfortable sensation that the tic alleviates. When the urge is experienced, the child learns to respond with a competing action that replaces the tic, such as taking a deep breath to replace a coughing or throat-clearing tic, or to stretch the hand out to replace a hand flipping tic, or yawning to replace a grimace; in each case the replacing action draws less attention than the tic. 

Diagnostically speaking, Persistent Motor Tic Disorder is given if motor tics, only, are present in one form or the other for over a year; Persistent Vocal Tic Disorder is diagnosed if vocal tics only, occur beyond a year. If both motor and vocal tics are present for longer than a year, the child will be diagnosed with Tourette’s Syndrome. This syndrome, the most well-known of ticcing disorders, is the one portrayed in books and movies. For a riveting look at Tourette’s in a young adult, check out Dr. Oliver Sacks’ recounting of his treatment of a 24-year-old man with the syndrome in the chapter entitled Witty Ticcy Ray, in his book The Man Who Mistook His Wife for a Hat. 

A: Besides anxiety, many children with tic disorders also experience depression because of the social implications of having tics, as well as the disruption severe tics cause in their daily lives. How do we as parents help our children stay accepting of themselves as they try to contain a nervous habit?

V: I think the unvoluntary nature of tics is a great place to start. Explain the tics to our children who are experiencing them. By sharing the unvoluntary aspect of the tic, the issue of “fault” is taken care of, in that, there is none. Kids are not making the behavior happen. It is not their fault, but they do have power to understand and address the source of their sadness and stress.

We can help our kids understand that lots of kids have worries and nervousness about lots of different stressors such as the dark, attending school, spiders, performing on stage, etc and the stress is expressed in very unique ways, some more visible than others. We can add clarification by distinguishing between a tic and a habit through the use of examples. For example,  frequent eye blinking and grimacing are likely tics, while nail-biting, twirling your hair or pulling at your collar are more likely habits; they all share the common ground in that they may all be more likely to emerge when anxiety is high.

Explaining what happens in the brain can give older children a deeper understanding around their tics. Dr. Susan Scheftel, Assistant Clinical Professor of Medical Psychology and Psychiatry at the Columbia Psychoanalytic Institute for Training and Research, shares that, “from a neuropsychiatric point of view, tics represent motor disinhibition, a way that the more primitive part of the brain probably breaks through and hijacks the more demure higher cortical functions. Though many people with tics have other comorbidities, or other conditions that are often seen in tandem with tics, such as ADD or OCD, tics are all about wayward impulses and actions.”

Depressive moods, or anxiety that may emerge from being teased or bullied because of having a tic, especially a very visually arresting one, can be worked through with much patience and compassion from parents and extended family at home, and with the support of teachers and counselors at school. 

When our kids’ bodies and minds are feeling tired and depleted, ticcing is more likely to occur. So engaging in some slowing down, breath-deepening exercises for relaxation that I described earlier, may help lessen the ticcing. Additionally, mindfulness and grounding strategies can help, such as:

  • identifying five things you see, four things you can touch or feel, three things you hear, two things you can smell and one thing you can taste, can bring awareness to the present moment and take the focus off the tic.
  • making random lists, such as top 5 movies, favorite 3 songs or 5 favorite recipes Mom makes, again to distract the brain away from the anxiety producing stimulus. 
  • implementing the steps of Habit Replacement Therapy: Recognize premonitory urge; engage in replacement action, can shift energy to that action and disguise the presence of the tic. 
  • those who find tactile stimulation calming may benefit from keeping a small, smooth rock or swatch of fabric in their pockets to hold in their hands and rub as a way to help them feel calm.

To pre-emptively prepare our kiddos to better weather, and perhaps even avoid ticcing episodes, we can help fortify them.  Establishing a great sleep routine of at least 9-10 hours, allowing for plenty of time for relaxation and free play/expression, keeping them from becoming over-scheduled with extracurricular activities, and maintaining close, connected relationships with loved ones helps keep the focus on life’s natural rhythms, hopefully keeping the tics as nothing more than a transient visitor. 

A: Once again, thank you Vinay for sharing your expertise with us!

For more information about childhood tics:

https://childrensmd.org/uncategorized/kids-tics-whats-normal-see-specialist/

https://childmind.org/article/tics-and-tourettes/

https://www.psychologytoday.com/us/articles/200503/tics-part-growing

https://www.psychologytoday.com/us/blog/mental-wealth/201203/got-tics-environmental-adjustments-can-help-0

https://www.psychologytoday.com/us/blog/evolving-minds/201505/tics-are-kids

Vinay Gaglani is a Pacific Northwester of Indian descent who aspires to be a peaceful parent to her two amazing young boys. Vinay is a Licensed Professional Counselor by trade, and a lover of hiking and drinking tea!

 

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