Tic disorders, including Tourette syndrome, involve sudden repetitive movements or sounds beginning in childhood that wax and wane over time. Mild tics need education and monitoring only; bothersome tics are treated first with Comprehensive Behavioral Intervention for Tics (CBIT) and, when needed, medications such as guanfacine, clonidine or aripiprazole. Co-occurring ADHD and OCD are treated alongside.
Tourette syndrome is diagnosed when both motor and vocal tics have been present for more than a year, beginning before age 18. Persistent motor or vocal tic disorder involves one type for more than a year, and provisional tic disorder describes tics of less than a year. All of these are common in children, and most are mild. Tics themselves often need no treatment; what brings families to a psychiatric practice is usually the ADHD, OCD, anxiety or depression that accompany tics in most cases, or tics severe enough to cause pain, embarrassment or disruption. At Stedfast Psychiatry we treat the whole picture, with behavioral therapy for tics as the first choice and medication when it is needed.
Symptoms of tic disorders
- Simple motor tics: eye blinking, facial grimacing, nose twitching, head jerking, shoulder shrugging
- Complex motor tics: touching, tapping, hopping, imitating others' movements, or sequences of movements
- Simple vocal tics: sniffing, throat clearing, grunting, coughing, squeaking
- Complex vocal tics: words, phrases, repeating others (echolalia) or oneself (palilalia); uttering obscenities (coprolalia) in a minority
- A premonitory urge, a sensation of tension or itch relieved by performing the tic
- Ability to suppress tics briefly, followed by a rebound
- Tics that worsen with stress, excitement, fatigue or illness and lessen during focused activity
- Co-occurring ADHD, obsessive-compulsive symptoms, anxiety, learning problems or sleep difficulty
Causes and risk factors
Tic disorders are neurodevelopmental and strongly genetic. Having a parent or sibling with tics or OCD raises risk substantially, and twin studies show high heritability. The underlying biology involves the cortico-striato-thalamo-cortical circuits that select and inhibit movements, with altered dopamine signaling in the basal ganglia; this explains why dopamine-modulating medications reduce tics. Tics are not caused by anxiety or by parenting, though stress makes them worse, and they are not under conscious control.
Environmental contributors include prenatal and perinatal factors such as maternal smoking and low birth weight. Tics can be exacerbated by stimulant medications in some children, though large studies show that stimulants do not cause tic disorders and most children with ADHD and tics tolerate them. Streptococcal infection has been proposed as a trigger in a small subgroup (PANDAS), but this remains controversial and does not apply to most children with tics. Sudden-onset tic-like behaviors in adolescents, particularly with social media exposure, are a distinct functional phenomenon that we distinguish from Tourette syndrome.
Tourette syndrome affects an estimated 1 in 162 children (0.6 percent) in the United States, and transient tics occur in up to 20 percent of school-age children.
Source: Centers for Disease Control and Prevention
About 86 percent of children with Tourette syndrome have at least one co-occurring mental, behavioral or developmental condition, most often ADHD or OCD.
Source: CDC, National Survey of Children's Health analysis
Comprehensive Behavioral Intervention for Tics produced significant improvement in 52.5 percent of children compared with 18.5 percent receiving supportive therapy in a randomized trial.
Source: Piacentini et al., JAMA, 2010
The American Academy of Neurology practice guideline recommends CBIT as first-line treatment and lists alpha-2 agonists and antipsychotics among medication options, with aripiprazole FDA-approved for Tourette's disorder in children.
Source: Pringsheim et al., Neurology, 2019
How we diagnose it at Stedfast Psychiatry
Tic disorders are diagnosed clinically. We take a history of the tics from the child and parents: age of onset, types, frequency, premonitory urges, course over time, triggers and impact. Tics often do not appear during the visit because focused attention suppresses them, so we ask parents to bring video from home. We use the Yale Global Tic Severity Scale (YGTSS) to rate tics and track response, and we distinguish tics from stereotypies, compulsions, myoclonus, chorea and functional tic-like behaviors.
Because co-occurring conditions are the main source of impairment, we screen carefully for ADHD (Vanderbilt scales), OCD (CY-BOCS), anxiety (SCARED), depression (PHQ-A), learning problems and sleep disorders. We also screen for rage attacks and self-injurious tics, which change management. Neurological examination is normal in Tourette syndrome; when tics begin abruptly in a child with no family history, when there are other neurological signs, or when the movements are atypical, we refer to a pediatric neurologist and consider further testing. Laboratory tests and imaging are not needed for typical tic disorders.
Treatment options
Medication management
Medication is used when tics cause pain, injury, significant social or academic problems, or distress that behavioral therapy has not relieved. The alpha-2 agonists guanfacine extended-release and clonidine extended-release are the usual first choice, particularly when ADHD is also present, because they reduce both tics and hyperactivity with a favorable side-effect profile (sedation and lowered blood pressure are the main concerns). When tics are more severe, the atypical antipsychotics aripiprazole (FDA-approved for Tourette syndrome in children 6 to 18) and risperidone are effective; we monitor weight, glucose, lipids and movement side effects. Older agents such as haloperidol and pimozide are FDA-approved but reserved for refractory cases because of their side effects. Topiramate and the VMAT2 inhibitors (tetrabenazine and its newer relatives) are options in specific situations. For co-occurring ADHD, stimulants are usually safe and effective; if tics worsen we adjust the dose or combine with guanfacine. For OCD, SSRIs such as fluoxetine or sertraline are first line. We start low, increase slowly, and reassess the need for tic medication regularly because tics naturally fluctuate and often diminish in adolescence.
Psychotherapy
Comprehensive Behavioral Intervention for Tics (CBIT) is the first-line treatment for bothersome tics, recommended by the American Academy of Neurology. Over about eight sessions, the child learns to recognize the premonitory urge, to perform a competing response (a movement that is physically incompatible with the tic) until the urge passes, and to identify and modify situations that make tics worse. In randomized trials, CBIT reduced tic severity in more than half of children and adults, with lasting benefit. It does not make tics worse or cause them to be replaced by others, a common fear. For co-occurring OCD, exposure and response prevention is the standard. For anxiety, cognitive behavioral therapy. Psychoeducation for the family and school, including accommodations such as extra time, testing in a separate room and permission to leave class when tics are intense, reduces the burden substantially. Our therapists coordinate with the prescriber so that the plan is unified.
What to expect
The first visit is a 60 to 90 minute evaluation with the child and parents, with rating scales and home video reviewed. You will leave with a diagnosis, an explanation of the expected course, and a plan that begins with education and, when tics are bothersome, CBIT. Medication is added when needed for tics or for co-occurring conditions. Follow-ups are every two to four weeks during medication adjustment and every one to three months otherwise, with the YGTSS repeated to track change. CBIT and most follow-ups can be done by video anywhere in Florida or South Carolina.
When to seek help
Make an appointment if tics are causing pain or injury, interfering with school, sleep or friendships, causing your child distress or embarrassment, or if your child also shows signs of ADHD, OCD or anxiety. Seek help sooner if tics began abruptly and severely, if there are rage attacks, or if your child is being bullied or has become withdrawn or sad. If your child expresses thoughts of self-harm, call or text 988, the Suicide and Crisis Lifeline, or go to the nearest emergency room.
Types of tic disorders
The DSM-5 recognizes three primary tic disorders, distinguished by duration and type. Provisional tic disorder: motor and/or vocal tics for less than one year, the most common form, affecting up to one in five children at some point and usually resolving. Persistent (chronic) motor or vocal tic disorder: either motor or vocal tics, but not both, for more than one year. Tourette syndrome: multiple motor tics and at least one vocal tic, not necessarily at the same time, for more than one year, with onset before age 18. All require that the tics are not caused by a substance or another medical condition. The names describe duration and pattern rather than severity; a child with persistent motor tic disorder can be more affected than one with mild Tourette syndrome.
The conditions that travel with tics
The majority of children with Tourette syndrome have at least one co-occurring condition, and these usually cause more impairment than the tics. ADHD affects roughly half and is often the main reason for school difficulty. Obsessive-compulsive symptoms affect a third to a half and in Tourette syndrome often take the form of symmetry, counting and just-right compulsions rather than contamination fears. Anxiety disorders, depression, learning disorders, sleep problems, rage attacks and, in some, autism spectrum traits are common. Treating these conditions is the core of psychiatric care for tic disorders, and it often reduces tics indirectly by lowering stress.
Differential diagnosis
Stereotypies are rhythmic, patterned movements such as hand flapping or rocking that begin before age three, last longer than tics, have no premonitory urge and are seen in autism and in typically developing children. Compulsions are purposeful behaviors done to reduce anxiety or prevent a feared outcome. Myoclonus, chorea, dystonia and seizures are distinguished by their pattern, lack of suppressibility and associated findings, and warrant neurological referral. Functional tic-like behaviors, which increased sharply among adolescents during and after the pandemic, have abrupt onset, complex and often injurious forms, lack a premonitory urge and are treated with psychological approaches. Medication-induced movements (from stimulants, antipsychotics or lamotrigine) are identified by timing.
Tics and school
Tics are often most visible and most distressing at school. Accommodations that help include seating that allows the child to leave discreetly, permission to take breaks, testing in a separate room with extra time, no penalty for tic-related noises or handwriting, and brief education for classmates when the child and family agree. A 504 plan documents these. Teachers should not ask the child to stop ticcing, which is impossible and increases anxiety, and should respond to bullying firmly. We provide letters and, with consent, speak with school staff.
Living with tics
Good sleep, regular exercise, stress reduction and a predictable routine all reduce tic frequency. Caffeine worsens tics in some children. Drawing attention to tics tends to increase them, so families are advised to treat them as background. Tic-suppressing in public is tiring and often followed by a release at home, which parents should expect and not interpret as the child saving the worst for them. Support organizations such as the Tourette Association of America offer education, camps and peer connection that many families find valuable.
Prognosis
Most children with tic disorders improve with age. Tics usually peak between ten and twelve and lessen through adolescence, with roughly two thirds of adults having no or mild tics. Co-occurring ADHD, OCD and anxiety may persist and respond to their own treatments. With education, CBIT and judicious medication, the great majority of children with tic disorders attend regular school, maintain friendships and go on to normal adult lives. The goal of treatment is not the absence of tics but a child who is not limited by them.
Frequently asked questions
Do tics need to be treated at all?
Often not. Many tics are mild, cause no distress and fade on their own; about one third of children with Tourette syndrome have minimal tics by adulthood, and another third have mild ones. Treatment is for tics that cause pain, injury, social or academic problems, or distress, and for the co-occurring ADHD, OCD or anxiety that are usually more impairing than the tics themselves. The first step is always education for the child, family and school, which by itself reduces the burden.
What is CBIT and does it work?
Comprehensive Behavioral Intervention for Tics is a structured therapy, usually eight sessions, that teaches the child to notice the urge before a tic and to perform a competing movement until the urge passes, along with strategies for situations that worsen tics. In a large randomized trial, more than half of children improved significantly, compared with fewer than a fifth with supportive therapy, and gains lasted at follow-up. It does not suppress tics in a way that causes them to burst out later, and it does not cause new tics. It is now the recommended first treatment.
Which medication is used for tics?
Guanfacine extended-release or clonidine extended-release are usually tried first, especially when ADHD is also present, because they reduce both and are well tolerated. Aripiprazole, FDA-approved for Tourette syndrome in children, is used for more severe tics, with monitoring for weight gain and metabolic changes. Risperidone is an alternative. Haloperidol and pimozide are older FDA-approved options reserved for refractory cases. The right choice depends on severity, co-occurring conditions and side-effect concerns, and the dose is kept as low as possible.
Will stimulants for ADHD make tics worse?
Usually not. The belief that stimulants cause tics came from early case reports, but large controlled studies show that methylphenidate does not increase tics on average in children with ADHD and tic disorders, and most tolerate it well. In the minority whose tics do worsen, we lower the dose, switch to a different stimulant, add guanfacine, or use a non-stimulant. Untreated ADHD is generally more harmful to a child's functioning than a modest increase in tics, so we treat the ADHD.
Does Tourette syndrome mean my child will swear uncontrollably?
Coprolalia, the involuntary utterance of obscene words, occurs in only about 10 percent of people with Tourette syndrome and is one of the least common tics, despite its prominence in media portrayals. Most tics are simple movements and sounds like blinking, sniffing and throat clearing. When coprolalia does occur it is distressing and responds to the same treatments as other tics.
My teenager developed sudden severe tics after watching videos online. Is that Tourette's?
Probably not. Since 2020, clinics have seen many adolescents, mostly girls, with abrupt onset of complex, dramatic tic-like movements and vocalizations that differ from typical tics: later onset, no premonitory urge, no waxing and waning history, and often resemblance to behaviors seen on social media. These functional tic-like behaviors are real and distressing, but they are treated differently, with education, cognitive behavioral therapy, reduced exposure to tic content and treatment of underlying anxiety or depression, rather than with tic medications. A careful evaluation distinguishes them.
Is tic treatment covered by insurance and available by telehealth?
Yes. Evaluation, medication management and CBIT are covered by most commercial plans and the Medicaid managed care plans we accept; a self-pay new-patient evaluation is $185. Generic guanfacine, clonidine and aripiprazole are inexpensive. CBIT has been shown to work by video, and we deliver it and most follow-ups by telehealth throughout Florida and South Carolina, with in-person care at all 13 offices.
What happens to tics as my child gets older?
Tics typically start around age five to seven, peak in severity between ten and twelve, and then improve for most people through adolescence. By early adulthood roughly a third have essentially no tics, a third have mild tics and a third continue to have moderate or severe tics. Co-occurring ADHD and OCD follow their own courses and often need continued treatment. We revisit the need for tic medication regularly, because many adolescents can taper it as tics subside.
Where to get treatment for Tourette syndrome and tic disorders
Evaluation and treatment for Tourette syndrome and tic disorders is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.