Tics in Children and Adolescents: What They Are, Why They Happen, and When to Seek Help

Tics are relatively common in childhood and adolescence and can be very worrying for parents, especially when they appear suddenly or are noticed at school. The good news is that transient tics are often benign and have a good prognosis, but it is important to know when to monitor and when to seek a more detailed assessment.

This article is for informational purposes and cannot replace an individual clinical evaluation.

What are tics?

Tics are involuntary, sudden, rapid, repetitive, non-rhythmic motor movements and/or vocalizations. They are typically brief, may occur in bursts, and appear to have no clear purpose.

The literature often highlights additional features of tics:

a tic can sometimes be suppressed for a short time
suppression may cause discomfort or a sensory urge before the tic
performing the tic is often followed by short-term relief
tics can be highly suggestible, meaning they may increase when talked about or when the child becomes more aware of them

Important: in younger children, the sensory urge may be absent and is more commonly reported after around age 10.

What does a tic cycle look like?

For many children and adolescents, a tic can follow a repeating pattern:

an unpleasant premonitory sensation (like an internal itch)
rising tension
the tic occurs
brief relief (seconds to minutes)
the urge returns

This is one reason tics may seem semi-voluntary: a child may be able to suppress them briefly, but often at the cost of increasing tension.

Types of tics (motor vs. vocal; simple vs. complex)

Tics can be classified:

by manifestation: motor or vocal
by complexity: simple or complex

Simple motor tics

Examples include:

eye blinking
facial grimacing
head jerking
shoulder shrugging

Complex motor tics

These may look purposeful or elaborated, for example:

running or hopping movements
complex grasping or movement patterns
self-hitting (less common, but clinically important)

Special forms:

echopraxia (repeating other people’s movements)
copropraxia (complex obscene gestures)

Vocal tics

Vocal tics can range from simple sounds to more complex vocalizations.

Examples of simple vocal tics:

throat clearing
sighing
sniffing
squeaking

Complex vocal tics:

shouting
whistling

Special forms:

coprolalia (uttering obscene words)
palilalia (repeating one’s own words)
echolalia (repeating other people’s words)

Why do tics get worse with stress or excitement?

Tics typically increase:

during stress and tense situations
during excitement
with boredom

They often decrease or disappear during sleep, though not always. Tics can fluctuate, changing over time in intensity and in where they occur in the body.

Tics may be associated with:

shame
lower self-esteem
social isolation

That is why it is important not to focus only on the movement itself, but also on how the child experiences it.

According to DSM-5, three main entities are described:

Provisional (transient) tic disorder
- motor and/or vocal tics
- duration less than 1 year
Persistent (chronic) motor or vocal tic disorder
- motor or vocal tics, but not both
- duration more than 1 year
Tourette syndrome
- multiple motor tics plus at least one vocal tic, not necessarily at the same time
- duration more than 1 year

In practice, clinicians often describe a tic disorder spectrum, ranging from transient tics to Tourette syndrome.

When do tics usually start?

transient tics: typically between ages 3 and 10
Tourette syndrome: often begins around age 6 with motor tics; the full clinical picture commonly develops around age 11, when vocal tics may appear

How common are tics?

transient tics: 4 to 24% of school-age children
chronic tics: about 1 to 4%
Tourette syndrome: reported in children and adolescents from 1 in 100 to 1 in 10,000

Tics are more common in boys than in girls.

What does a professional assessment involve?

Assessment is based on a detailed history and collateral history, because children may sometimes minimize symptoms, focusing on:

type of tic (motor/vocal; simple/complex)
number, intensity, and frequency
fluctuations and changes in localization
whether the child can suppress the tic and what happens when they do
interference with functioning (school, relationships, self-confidence)
triggers and situational context
medication use (e.g., methylphenidate)

Depending on the clinical picture and specialist judgment, additional evaluations may be recommended:

pediatric and neurological examination
laboratory workup
EEG when indicated
monitoring antistreptolysin titer when indicated (e.g., if PANDAS is suspected)
psychological assessment and attention/functioning evaluation
symptom rating scales (e.g., Yale tic scales)

What can look like tics? (differential diagnosis)

It is important to differentiate tics from other conditions, such as:

motor stereotypies
compulsions (OCD)
mannerisms
epileptic phenomena (e.g., absence seizures)
neurological conditions (e.g., chorea, facial spasm)
conversion symptoms

Comorbidities: what often occurs alongside tics?

Tics frequently co-occur with:

ADHD, often reported in up to about half of cases
OCD, reported up to 44%
anxiety disorders
behavioral disorders
depression

That is why it is important to assess the whole picture: sometimes a child suffers more from anxiety, ADHD, or OCD than from the tics themselves.

Treatment: what helps with tics?

Treatment should be comprehensive (multimodal) and flexible. Depending on severity and duration, options may include:

psychoeducation (child and parents)
supportive treatment (e.g., play therapy)
behavioral approaches (e.g., habit reversal therapy)
relaxation techniques
cognitive therapy
psychodynamic approach, especially in mild to moderate forms
parent work and, when needed, family therapy
medication, not as first-line treatment, but considered for severe tics and/or significant comorbidity

The goal of treatment is usually not complete disappearance of tics, but making them more manageable and improving daily functioning.

Guidance for parents and teachers

Tics are not intentional, and it is important to explain this clearly to both the child and the environment.
Avoid excessive attention to the tics, because constant commenting can increase symptoms.
Treat the child as normally as possible, with a supportive approach.
Do not wait too long if there is distress, social withdrawal, or functional impairment.
Consider stressors and family context, because transient tics often have stress in the background.

When should you seek professional help?

An assessment is recommended if:

tics last longer than a few weeks and are increasing
tics persist longer than 12 months
both motor and vocal tics are present
the child experiences significant distress, shame, school avoidance, or peer difficulties
there are signs of comorbidity (ADHD, OCD, anxiety, depression)
there are self-injurious tics or risky behaviors

When should you book an appointment?

If you have noticed tics in your child or adolescent and you are unsure whether this is a transient phenomenon or something that requires a structured assessment, it can be helpful to schedule a professional evaluation and agree on a monitoring plan.

At Poliklinika Golden Mind (Zagreb), we assess tics and common comorbidities (ADHD, OCD, anxiety) and can recommend psychotherapy and other supportive approaches when indicated.

FAQ

Should transient tics be treated?

Views differ in the literature, but in practice an initial evaluation, monitoring, and parent guidance are often recommended, because at the beginning it is not always clear whether symptoms will resolve quickly or persist.

Are tics a sign of bad parenting?

No. Tics are not a choice, and a child cannot fully control them.

What is PANDAS?

PANDAS is a pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection, classically linked with OCD and tics. Evaluation and workup should be done in collaboration with a pediatrician or neuropediatrician and a child psychiatrist.