Tics are involuntary vocalisations or repetitive movements that may involve any part of the body. Typically motor tics may be eye blinking, grimacing, nasal flaring, shoulder shrugging or head jerking. Vocalisations may involve throat clearing, humming, grunting or sniffing. Complex tics are repetitive coordinated patterns of movement. Vocal complex tics produce an actual word rather than just a sound. Tics are stress-related and often appear for the first time when a child is in a particularly stressful situation.

Tics may occur for just a short time, they may come and go, or they may be a constant feature of a child’s behaviour. If a child suffers from tics over a long period they are likely to change – from eye blinking to shoulder shrugging, throat clearing to sniffing, for example. They tend to be strongly inherited and more common in boys.

Most children with tics have immaturities in differentiation, so there may be a tendency to overflow motor activity, fidgeting and poor handwriting. A high degree of hypersensitivity is also common, which may result in high levels of anxiety and stress. Adults may develop depression. It is also common for children with tics to also show symptoms of Attention Deficit Hyperactivity Disorder (ADHD) or Obsessive Compulsive Disorder (OCD). Many children will fit into the Enigma/T-type label.

Tourette Syndrome

Tourette Syndrome is diagnosed when a child has a combination of vocal and motor tics which have lasted more than a year and there is significant impairment. It is associated with imbalances in the neurotransmitters dopamine, serotonin and norepinephrine. Often the tics are accompanied by attention deficit, hyperactivity, obsessive compulsive disorders, anxiety or depression.

Suggested action

Tics are stress related and beyond a child’s control. They are best ignored, because asking the child to stop will increase their stress and make it more likely that the tics will continue. They can be transient and apparently unconnected with any learning or behavioural issues, or they may be associated with the full Tourette Syndrome. Often they are part of a pattern of difficulties which may affect a child’s performance, particularly associated with visual processing, motor difficulties and hypersensitivity. Sorting out these problems should result in less stress and consequently reduce the incidence of tics.

Case histories

ALLAN

Presenting difficulties

Allan had a tic, just a little tic at first; he used to blink a lot. Then he started coughing, a lot, especially when he was anxious, and this disturbed the other children in the classroom. He was a very anxious child, always ready to cry. His speech development was very late, and for a long time all he would do was to repeat exactly what someone else had just said, echolalia. He could also be obsessive. He was impulsive, distractible, excessively fidgety and incapable of concentrating. He was seen by the school’s educational psychologist, who did not know anything about the tics and he was labelled as a child with a low I.Q., speech and language difficulties and behavioural issues.

Allan was clumsy, poorly coordinated and totally confused about location and direction, and there was always a great deal of overflow movement to his body when he was trying to work, which could easily be misinterpreted. He was totally hypersensitive, too, so he was very easy to wind up.  He had no idea of time and could not make a start on things or see them through to completion, unless a particular obsession was involved, such as a computer game. He was in a world of his own most of the time, unaware of other people, or events going on around him. At seven years old he couldn’t read, couldn’t spell words for himself and had trouble with writing his numbers.

Assessment

Allan had difficulty with all the main building blocks for sensory integration and he was hypersensitive in every sensory area. He had also retained many of the primitive reflexes that should have been integrated, particularly the withdrawal reflex which was governing a lot of his behaviour. As a result of this all of his higher order processing was immature. His motor control was poor, he could not listen properly, he could not process visual information properly and could not integrate information. He was only using his left ear when listening, which meant that everything was being processed emotionally without much access to logic and life in the classroom was mainly about survival. There was no space for learning.

Progress

Soon after Allan started the programme he began to ask a lot of questions, which is something that toddlers do a great deal but Allan never had, but progress to begin with was slow. After eight months he began to take off, however. He was reading books with his mother and she noticed that his eyes had begun to sparkle. He was able to tackle a lot more by himself. His coughing tic was disappearing, but he had started to smell his hands instead. 

At this point Allan changed schools and he was in trouble in the first week for failing to comply with instructions to keep off the grass, and then talking back to the teacher who told him off. Nobody understood that he was emotionally hypersensitive and never deliberately naughty, and it took months to calm him down. He continued to be agitated and angry for several months and his sleeping was very poor, but five months later and eighteen months after the start of the programme he began to calm down. He was sleeping better and beginning to do quite well at school. A speech and language therapy review found him to be age-appropriate in most areas, although he still needed help in the classroom to keep him on track. This was tremendous progress, because his difficulties originally were severe. His reading was much better, and he had more concentration in the classroom.

In the next two or three months he continued to make excellent progress. He was able to recover from outbursts of temper very quickly and he seemed altogether more mature. He could now sit in an adult fashion, without sprawling and fidgeting. His writing was a lot neater and he now really wanted to learn to spell words. During the following term everything seemed to come together and his teacher described him as a different child. He was getting a lot more done in the classroom and was back in the mainstream. He would only see the Special Needs teacher for stress relief and help with spelling and writing. He also struggled with abstract concepts. He could still get frustrated, he would smell his hands a lot and was a bit of a loner at school, but he was a happy little boy at home.

Allan later managed the transition to senior school without difficulty and is achieving at the national average in most areas of the curriculum. He loves school, especially science, and he is well liked by his class mates. He still has extra help in literacy and maths and has two sessions a week in the special needs area, but he needs no support otherwise and he gets on with his homework well. He can get frustrated sometimes, but in general his teachers say that he appears more mature than most of his class.