FAQs Regarding Pediatric Tics: Prevalence, Causes, and Treatment Options

May 23, 2023 By Dr. Caroline Adelman, PhD

What are tics, and how common and persistent are they?

Tics are characterized by sudden, rapid, repetitive, and involuntary movements or vocalizations. The prevalence of tics in children varies, but it is estimated that as many as 20% of children experience tics at some point between the ages of 6-17, with boys being affected 3-4x more often than girls.

The majority of these pediatric tics are transient in nature. Transient tics are temporary and usually resolve on their own within a year. They are distinct from chronic tic disorders such as Tourette syndrome, which have a longer duration. Transient tics are also typically milder and have a lower impact on daily functioning, compared to chronic tic disorders.

Tics typically emerge between the ages of 2 and 15, with the average age of onset being around 6 years old. Many cases of pediatric tics, particularly transient tics, tend to improve or resolve on their own over time without specific treatment. Studies suggest that approximately 50-75% of children with tic disorders experience a significant reduction in tic severity or complete remission by adulthood.

What are the most common types of tics observed in children?

Tics in children may encompass a range of sudden, rapid, and repetitive involuntary movements or vocalizations. The most common pediatric tics include:

Motor Tics

Eye blinking: Rapid and repetitive blinking of the eyes.
Facial grimacing: Involuntary contractions of facial muscles, resulting in facial distortions.
Head jerking: Sudden and quick movements of the head in any direction.
Shoulder shrugging: Elevating and lowering of the shoulders in a repetitive manner.
Limb movements: Involuntary movements of the arms or legs, such as arm flapping or leg kicking.

Vocal Tics

Throat clearing: Repetitive and forceful expulsion of air from the throat.
Grunting: Uncontrolled vocal sounds produced in the back of the throat.
Sniffing: Involuntary and repeated inhalation through the nose.
Coprolalia (rare): The utterance of socially inappropriate or offensive words or phrases.

It’s important to note that tics can vary widely in type and severity from one individual to another. In addition to the distinction between motor and vocal tics, tics can be classified as simple (brief and isolated) or complex (coordinated and sequential). They may also be classified as transient (short-term) or chronic (present for 12+ months). Tics can also change over time for the same individual, with new tics emerging and old ones resolving or changing in intensity. Additionally, tics can temporarily worsen in response to stress, excitement, or fatigue.

When motor or vocal tics last 12 months or longer, a child may be diagnosed with Chronic Motor or Vocal Tic Disorder. When children or teens experience both motor AND vocal tics for 12+ months, they may be diagnosed with Tourette’s Syndrome. Approximately 1% of children will meet criteria for a Chronic Motor or Vocal Tic Disorder or Tourette’s Syndrome at some point in childhood.

If you suspect that a child is experiencing tics, you may wish to consult with a healthcare professional for a comprehensive evaluation and accurate diagnosis.

How are Pediatric Tics Diagnosed?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides diagnostic criteria for tic disorders, including Tourette syndrome and persistent (chronic) motor or vocal tic disorders. The diagnosis of a tic disorder can only be made by qualified healthcare professionals, such as psychologists, psychiatrists, or neurologists, with appropriate training and expertise. A comprehensive evaluation, including a thorough clinical assessment and consideration of other factors, is necessary for an accurate diagnosis.

What Causes Tics?

We are still learning a lot about the various factors that contribute to the development and maintenance of tics, and we know there is no single factor that predicts who will develop tics. Below are some factors currently thought to play a role in the development of tics and tic-related disorders.

Brain Circuitry: Current research suggests that abnormalities in the cortico-basal ganglia-thalamo-cortical circuit of the brain play a significant role in the development of tics. This circuit involves interconnected brain regions, including the cortex, basal ganglia (particularly the striatum), thalamus, and related pathways. Dysfunctions within this circuitry, involving imbalances in neurotransmitters such as dopamine and gamma-aminobutyric acid (GABA), may contribute to the occurrence of tics.
Genetic Factors: There is evidence to suggest a genetic component in the development of tics, as tics often run in families. Several genes have been implicated in tic disorders, with variations in these genes potentially affecting the development, structure, or function of the cortico-basal ganglia-thalamo-cortical circuitry. Families with genetic “loading” for Obsessive Compulsive Disorder and Attention-Deficit/Hyperactivity Disorder (ADHD) also seem to have increased genetic risk for the development of tics.
Environmental and Neurodevelopmental Factors: Environmental factors, such as prenatal and perinatal complications, maternal smoking during pregnancy, and exposure to certain toxins, may contribute to the development of tics. Neurodevelopmental factors, including alterations in brain development or connectivity, may also play a role. Although these factors may contribute to the development of tics for some individuals, there are many other underlying causes of tics and these factors do not need to be present for the development of a tic disorder.
Neurotransmitter Imbalance: Dysfunction in the balance of neurotransmitters, particularly dopamine and GABA, is thought to be involved in the pathophysiology of tics. Increased dopamine activity or decreased GABA activity in specific brain regions may lead to hyperexcitability or disinhibition of the cortico-basal ganglia-thalamo-cortical circuitry, contributing to tic expression.

How are Pediatric Tics Treated?

Most transient pediatric tics will lead to minimal interference in a child’s day-to-day functioning, and will resolve on their own without treatment. For tics that are more chronic or disruptive, behavioral therapy, such as Comprehensive Behavioral Intervention for Tics (CBIT) or Habit Reversal Training (HRT), is a recommended front-line treatment for tics. The treatment approach focuses on teaching children/teens tic awareness, competing response training, and functionally compatible replacement behaviors.

CBIT has been studied and shown to be effective for children aged 9 and older. Research on CBIT has primarily targeted children and adolescents, as they are more commonly affected by tic disorders. The treatment typically involves active involvement and participation from the child and their family. While there is limited research specifically examining the efficacy of CBIT in younger children (i.e., below the age of 9), some clinicians may adapt and modify the treatment techniques to suit younger children’s needs. The decision to implement CBIT in younger children would be made on a case-by-case basis, considering the child’s individual circumstances, developmental readiness for this approach, and the professional judgment of the treating clinician.

Medications may also be considered for children with moderate to severe tics that significantly impair daily functioning. Commonly prescribed medications for tics include alpha-2 adrenergic agonists (e.g., clonidine, guanfacine) and antipsychotics (e.g., risperidone, aripiprazole). Eligibility for medication-based treatment of tics would need to be determined by a Neurologist, Pediatrician, or Child Psychiatrist with background in treating pediatric tic disorders.

If my child is experiencing tics but is too young to benefit from CBIT, and/or is not distressed by their tics, how should I respond?

If you observe your child experiencing tics, it is important to approach the situation with understanding, support, and appropriate guidance. Here are some general recommendations for parents of children experiencing tics:

Educate Yourself about Pediatric Tics: Take the time to learn about tics and tic disorders, including their characteristics, potential causes, and available treatments. This knowledge will help you better understand your child’s condition and provide appropriate support.
Maintain a Calm and Supportive Environment: Stay calm and neutral when you notice your child’s tics, as stress and anxiety can exacerbate tic symptoms. Never direct a child to stop engaging in tics, and never use punitive measures in an effort to stop your child’s tics. This approach will not work, and may create shame or anxiety around the tics. Try to also avoid drawing too much attention to the tics, as this may increase self-consciousness or anxiety for children experiencing tics, and excessive attention may also serve to reinforce tics for younger children. Provide appropriate reassurance and education by letting your child know that tics are common and manageable.
Practice Open Communication: Encourage open, non-judgmental communication with your child about their tics. Allow them to express any concerns or frustrations they may have. Answer their questions honestly and in an age-appropriate manner, using simple and reassuring language (e.g., “Hey buddy, have you noticed recently that you are doing a lot of fast eye blinking, and it may feel like it’s difficult not to do it sometimes? I think that may be something called a tic, and we can ask your pediatrician about it if we want to know for sure. It’s pretty common actually, and it’s nothing to worry about. If it ever starts to really bother you, or if you develop other tics that bother you, let me know and I’ll make sure you get support from an expert who can give you some tools to manage tics. Do you have any questions for me about tics?”)
Consult a Healthcare Professional if More Support is Needed: If you suspect that your child’s tics are interfering with their daily functioning or causing distress, consult a healthcare professional experienced in treating pediatric tics, such as a pediatrician, child psychiatrist, child psychologist, or neurologist. A medical evaluation can help determine the nature of the tics and guide appropriate management strategies.
Connect with Support Groups and Resources: Seek out support groups or connect with other parents of children with tics. Sharing experiences and learning from others can provide emotional support and helpful coping strategies. Utilize reputable resources, such as https://tourette.org/, or organizations dedicated to tic disorders, to access accurate and up-to-date information.

Remember, every child is unique, and the management approach may vary based on the duration, severity, and functional impact of the tics. Consulting with healthcare professionals who specialize in pediatric tics is essential for tailored guidance and treatment recommendations.