Since the start of the pandemic there have been patient reports as well as observations from professionals that there has been an increase in tic symptoms for both patients with a previous diagnosis of tic disorders and those with no previous history of tics.
Currently around 45% of my clients have been affected by a sudden onset of tics since the Covid-19 pandemic began. So much so I now run monthly support groups for families affected by this.
I wanted to provide some thoughts around these issues of increased tics.
This ‘situation’ of sudden onset of tics over the last 12 months appears to be mostly affecting girls between the ages of 12 and 16. These girls often have a back history or anxiety and/ or depression.
This is also affecting boys, just at a lower rate.
GP’s are still following the rule of ‘wait a year’ (it’s common in young children for tics to come and leave, waiting a year is a normal pathway for Tourette’s) before they will refer, but this needs to change, these children are not getting the support they need.
Firstly, let’s look at tic disorders and how they manifest.
Tics are common in young children. Evidence suggests that 18% of under 10-year-olds will have motor or vocal tics at some point in their childhood, these tics often go away after a short period of time. In most cases there is nothing to be worried about and tics should be ignored. These types of tics are called transient tic disorder.
A chronic tic disorder is when either motor tics or vocal tics are present on and off for more than a year.
Tourettes Syndrome (TS) is where there are two or more motor tics and at least one vocal tic, which have been present for more than one year. Tourette syndrome is a neurological, genetic condition that causes individuals to make involuntary sounds and movements called tics. These tics usually start in childhood and are often linked to other co-morbid conditions which individuals have alongside their tics. Such as but not limited to ADHD, OCD, Rage and Anxiety.
Transient, chronic and Tourette Syndrome tic disorders can be caused by a combination of genetics, neurological issues and chemical imbalance.
Functional tics (also known as functional movement disorder - FMD) are reported by roughly a third of new neurology outpatients. Functional tics happen when you experience involuntary movements within the body. Functional movements can be prevalent within individuals who also have TS; however, this often goes undiagnosed due to the similarities of the two.
Both TS & FMD have the kinematics of voluntary movements (although TS movements can appear more 'normal'). They both worsen with attention, are suggestable and distractible. They both also have common co-occuring conditions such as mood and anxiety disorders. However, they are different due to the following: FMD's onset is usually in older children/ teens and adults, these symptoms come on suddenly and in full force, symptoms usually are the same and present in a rhythmic pattern.
Paediatric Autoimmune Neurological Disorder Associated with Streptococcus (PANDAS) PANDAS is a condition seen in the paediatric population consisting of tics or obsessive-compulsive disorder exacerbated or brought on by a common bacterial infection called Group A streptococcus (GAS).
PANDAS symptoms typically start abruptly, almost as if a switch has been thrown. Symptoms include tics, sleep disturbance, obsessive compulsive behaviour, deterioration in handwriting, eating disorders (including anorexia but the problems appear to be more centred on difficulty in coordinating swallowing), behavioural regression and urinary incontinence. By definition these occur following a streptococcal infection which then results in the stimulation of antibodies which stimulates the part of the brain involved in movement and behaviour regulation (the basal ganglia).
Why is it important to learn what caused the tics?
As you can see there are many causes of tics, and the list above only touches on a few of them. I’m often asked why is it important to be clear about the different types of tics and does it really matter, as tics are tics, right?
WRONG!
The reason it’s important to seek the cause of these tics, especially if there is no genetic link is because these different tics are all treated differently. If any?!
As you can see by this table, there are many similarities, yet the treatment pathway is different for each of them.
Some people don't need treatment however if the patient wants or needs treatment, the recommended first line intervention for Tourette’s Syndrome by the American Academy of neurology is Comprehensive Behavioural intervention for Tics (CBiT) before medication is tried, That said often children are offered medication instead of or as well as behavioural therapy, due to lack of funding/ resources.
Treatment for functional movements is mostly therapy based with a main focus on the triggers that caused these tics, this will include anxiety and trauma management and learning about separating the mind from internal feelings/ sensations. Tic medication rarely works for functional tics, however anxiety medication can help in some cases.
Treatment for PANDAS is usually a combination of antibiotics, anti inflammatories and behaviour intervention is used for the remaining tics.
Why is there currently such an increase in tics and is Covid – 19 linked to this?
This year has been a strange one for all of us, the world came to a stop, children have so far missed nearly 12 months of their education and have witnessed the turmoil parents have seen themselves in with having to adapt their jobs, work from home, home educate their children and possibly struggle financially. This is not to mention the fear that would be travelling through their minds with lockdown, gloves, masks, not seeing loved ones and for some, having to deal with loss of a family member.
It’s been widely publicised that figures showing the increase in mental health issues and suicide in adults during the pandemic so is it really a surprise that our children are also struggling?
Whether your child had tics previously or not, personally I am not shocked by the fact our kids are struggling and for those of us with ‘ticcy’ brains that this is manifesting as tics.
There is speculation running around social media support groups with regards to this mass of sudden onset and its link to Covid-19. Parents questioning how many of these sudden onset cases have previously had a positive test result of the virus. This needs to be researched in more detail, but in my opinion Covid is unlikely to ‘cause’ tics BUT if there is an underlying immune condition such as PANS / PANDAS, then Covid could potentially bring on or worsen symptoms.
How to support the child – Parents
Firstly, try not to panic, although this is easier said than done, especially if tics have begun suddenly, panicking will only fuel your child’s reaction to these new tics.
· Sudden tics increase in previously diagnosed Tic Disorder: If your child already has a tic disorder but has suffered an increase in tics over the lockdown period or when first returning to school, this is most likely been caused by increased anxiety and this has exacerbated their symptoms. Ensure school are fully aware of the support and provisions needed to help reduce anxiety at school and encourage your child to carry on as best they can as these symptoms should decrease once back in school. Ignoring tics is always important both at home and school.
· Sudden onset of tics with a history of a tic(s) when they were younger: If your child has previously had tics, even as small as a period of excessive blinking, age 5 for 2 months and nothing since, they were most likely going to get tics at some point but almost needed a trigger to bring them out. It would be worth seeking a referral to explore chronic tic disorder / Tourette’s Syndrome diagnosis. Again, ensure school are aware that your child has tics in the past, that they may require some reasonable adjustments whilst you seek a diagnosis and again remember, where possible the best thing for everyone involved is to ignore the tics.
· Sudden onset with no history of tics: As stated above, if tics come on suddenly, there is no genetic links and the child has no history of tics (even the mild ones) I would remind you to stay calm, go to your GP ask to be referred, however it’s really important that this is done discretely. There could be various reasons for the sudden onset, but if its due to anxiety (FMD) the worst thing we as parents can do is freak out and start carting our children off to every doctor who will listen. Book appointments where necessary, do your own research so when you’re at the GP you can mention functional tics and PANDAS but most importantly, ignore the tics!! If you take anything from this article let it be this, ignoring tics is extremely important. I understand as parents we are conditioned to care for our children, comfort them, but the best thing we can do is reassure them and ignore the tics.
TikTok - If your child watches videos on the app TikTok of people with tics, I strongly advise against this. Tics are incredibly suggestive, especially tics of a functional nature. Watching these videos can increase tics and reinforce them.
How to support the child - School
· Regardless of whether tics are new or not, tics should be ignored wherever possible. Tics come via the basal ganglia, our basil ganglia are designed to give feedback to itself, so we know whether or not to do something again. This process happens for everyone, not just people with tics. If tics are given attention, this can trigger feedback and cause these tics to happen again in the same situation. This is a subconscious process and isn’t done deliberately.
· Speak to the pupil with tics about how they would like to proceed. A) do they want all staff informed (highly recommended), B) would they like their class/ school informed (also recommended, the quicker their peers are informed and educated the quicker attention will be diverted), C) ask the child where they prefer to sit, this may differ per lesson. It’s really important that the child can help you, help them, to reduce anxiety triggers and therefor their tics.
· Reduce the workload for the child if needed, many children with tics struggle to work at the same pace as their peers, tics do not affect a child’s intelligence however they can seriously impact their ability to learn. This does not mean lower the level to which they work, just the expectations around the quantity.
· If needed, a child with severe tics should access all exams in a separate room, with a stop the clock option, and some may need extra time.
· It’s also really important to be mindful that children with tics usually have co-occurring conditions, watch out for these and add in strategies to help support these too if possible.
· Children should stay in lesson as much as possible despite their tics, they should only leave in the most extreme circumstances, ideally children won’t’ be sent home from school due to their tics, the more they can do ‘business’ as usual’ the better it will be for them in the long run.
For more support in schools with tics, reach out to Lucy Toghill at Tourette’s Action.
How to support the child – GP
Dear GP, the tic community are seeing a rise in tics post lockdown and, in many cases, these are sudden onset, in teen girls, we appreciate that the normal process is to send families away and ‘wait and see’ however, in this instance we would request that you refer your patient to a tic clinic so they can assess and signpost treatment at the earliest possibility. There is a likely chance this could be a function tic disorder and the quicker your patient engages in therapy the better.
upcoming workshop on functional tics https://www.tictocktherapy.co.uk/event-details/a-brief-overview-of-functional-tics-2
Sarah Sharp
Tictock Therapy
CBiT Therapist
Signposting
For more information on PANS/PANDAS https://www.e-hospital.co.uk
For more information on Tourette’s https://www.tourettes-action.org.uk
For more information on Tourettes and functional tics http://www.psychiatria-danubina.com/UserDocsImages/pdf/dnb_vol31_noSuppl%205/dnb_vol31_noSuppl%205_732.pdf
To join support groups, I run https://www.tictocktherapy.co.uk/events-workshops