Tic Tips

Written by Mary M. Moebius, MD, FAPA
Diplomat of the American Board of Psychiatry and Neurology in General and Child Psychiatry, Assistant Clinical Professor, UCLA Semel NPI, private practice Tarzana, California

Fleeting motor tics are quite common in childhood and may not even be noticed as such. However, a passing tic can be quite distressing, usually for parents more so than for the child. The range I have seen has been from what I call the “ticky picky” behaviors to cartwheels, vomiting tics, and one I’ll never forget,”Dr. Mary Dr.Mary Dr. Mary”!

Contrary to popular belief, most tics are not Tourettes Syndrome (TS). TS require a minimum of 6 months of both a motor tic and a vocal tic. The classical swearing vocalizations are rare though TS is often portrayed this way in the media.

Here are some “tic tips” I’d like to share from years of working with children, teens, and an occasional adult, with tics.

In the olden days, we thought medications that treated Attention Deficit Disorder (ADD) caused tics to develop. It turns out that tics are especially common in children with ADD and even more so in boys with the diagnosis. Because the brain has to develop to certain points before certain symptoms can present, the symptoms of ADD usually present in kids under the age of 7 while tics present around the age of 9, by which time many are already being giving medications for the ADD. If a child with ADD is not treated with medications, tics still may present. Lo and behold, the meds were not the culprit after all.

Now that that has been said, I do see tics seem to present, worsen, improve, and even disappear in individuals who receive ADD medications. Some present only to disappear about two months after starting medication. Tic “seasons” are recognized with theories as to why they occur so consistently. In the beginning of my private practice in 1991, I began to notice tics presenting at the end of November around Thanksgiving, with improvement by the end of January. Was it that a child’s schedule was defined by change from this holiday on to the next with holiday performances, celebrations, and fluctuations in school schedules?

As the years went on, it seemed that tics also came around May then left by the 4th of July or soon thereafter. Then another brief blip would present in September.

Some symptoms of manic depression and depression worsen in May and September (peak suicide seasons, contrary to popular lore that the holidays are). Neuroimmunology studies associate the almost world wide tree bloom with an abundance of pollen as the culprit of over stressing the immune system and tipping the depression “centers” over the edge. Almost certainly allergens provoke an immunological tic response. This is more clearly known in PANDAS which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep where a child has a sudden on set of tics (or obsessive compulsive symptoms) around a bout of strep throat. The body’s immune system (that is fighting the germs) begins to fight itself and in this case sets off the movement centers of the brain. My experience is that any illness may bring out or worsen tics in the right person. Some of my families are able to tell when a child is becoming sick because the tics begin as a warning!

Another pearl about tics is that something frequently begets a tic. For example, the Santa Ana winds rise up, drying the air (releasing pollen too), lips become chapped and if one has the tic “seed” in the brain, lip licking ensues and “Clown Lips” appear from the repetitive tic lip licking (say that 3 times fast!). A throat clearing tic frequently starts after a cold or hay fever reaction as do eye blinking, sniffing, and coughing. Dr. Cesar Chavarria, a local pediatric pulmonologist, sees quite a few cough tics seasonally that are in a cycle as the cough irritates the breathing tubes which causes more coughing which irritates...

Tics also have a daytime rhythm. Usually when a child is well rested in the morning, then tics are quieter. The tics may be more under the person’s control during the day, at school, with others present, and while occupied. By the time the child gets home, is tired, and with the parent the tics may become so pronounced that the parent frets (understandably so) then stresses the child by scolding or highlighting the tic so that it worsens, becoming a family issue of contention.

What’s a parent to do?

First, relax. Take a few deep breaths, after all, how many adults have noticeable tics? With time, the cycles abate and your child will likely outgrow this. As family anxiety can heighten tics, lowering it can decrease the intensity. Both “good” stress and “bad” stress may exacerbate tics. Minimize the “bad” and roll with the good.

Treat hay fever with the guidance of your pediatrician, allergist, or ENT.

If your child’s tics began or worsen during or after a streptococcal infection, tell your doctor so you can have labs done, and begin appropriate antibiotic treatment if P.A.N.D.A.S. is present. (Pediatric Autoimmune Disorders Associated with Strep)

Prevent chapped lips, cuticles, scabs, dry eyes, prolonged coughs before a cycle of licking, picking, blinking, and coughing begins. Sunglasses help eye blinking. Hypnotherapy is my favorite active treatment when the above mentioned steps are not effective enough or the social stigma becomes a problem. Children and teens tend to be able to learn the self-hypnosis techniques taught to them by the hypnotherapists quite easily. Many times, a patient of mine will stop ticking the first time they are in a hypnotic state! Hypnosis is a “tool” one may use for life. Please be reassured that people don’t really do bizarre things under hypnosis when in with a trained professional.

Cognitive Behavior Therapy has also been shown to be effective. This is another “tool” one can take with them where ever they go, for life. Both hypnosis and CBT manage accompanying anxiety.

In only the most severe situations, do I recommend medications for the management of tics because the side effects and potential risks may outweigh the benefits? With that said, under supervision, these may be minimized and allow the opportunity for the less aggressive treatments to “kick in” when used together.

Clonidine and Tenex may be the first medication your doctor would use. Usually given in pill form, it may be taken once at night or up to three times a day, starting at low doses, increasing based on effects. Sometimes a child may feel sleepy at first but that usually goes away. Originally used to control high blood pressure, these medications were found to help the hyperactive component of ADHD as well as insomnia in medicated and non-medicated people with ADHD. An EKG may be done before starting these medications and about 6 weeks in to treatment. Monitoring for depression and weight gain is important too.

Catapress is the patch form of Clonidine.

Medications called Neuroleptics have been used for quite awhile to treat tics especially of the Tourettes Syndrome nature. Because of sedation, they frequently are given at night. Weight gain, Metabolic Syndrome (having labs such as fasting blood sugar, cholesterol, other lipids), abnormal body movements (not the tic itself) must be monitored closely. Other potential side effects should be explained by your doc. If a tic has a more obsessive compulsive quality to it a Selective Serotonin Reuptake Inhibitor may be tried. It’s almost hard to explain how to differentiate between some OCD behaviors and tics. It becomes a "gut" feeling so I recommend having a detailed discussion with your pediatric psychiatrist, neurologist or pediatrician.

Some nicotine and nicotine-like agents have been used but I have not felt comfortable trying them for fear of it becoming a “gateway” to cigarettes. However, if it works for your child, it may be worth trying it with a doctor experienced in its use.

I hope this article will help children, parents, siblings, and grandparents have a little more understanding as how best to ride the storm of the ever-changing weather pattern of tics.