The Child with Unusual Behaviours - Tics

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Section	Age	Indicator
Action	Early Childhood	Green
Belief	Middle Childhood	Yellow
Course	Early Adolescence	Red
	Adolescence

Tics are rapid, recurrent, stereotyped motor movements or vocalizations. They can last only a few seconds. They are repetitive, and can occur many times a minute or only a few times per hour. Tics are involuntary. They can be suppressed, but then the urge to have the tic becomes increasingly stronger until the tic is irresistible. Tics can change over time. They range from being hardly noticeable to very obvious, and can even be painful on very rare occasions.

There are three major types of tics: motor, verbal, and complex.

Motor Tics
- involve the whole body, but mostly the head and least likely the legs.
- Head
  - Eyes
    - For example, rolling, lifting eyebrows and squinting.
  - Mouth
    - For example, grimacing, twitching, pursing of lips
  - Complex Facial
    - For example, neck tics that involve hair tossing, head turning and thrusting,
    - These tics sometimes can be severe enough to cause pain
- Body:
  - less common and easy to disguise
  - these go along with neck and head tics.
  - Arms and Hands
    - Looks like startle response
    - tics can interfere with writing and drawing
  - Trunk
    - Twisting and thrusting of the hips
    - Tics can be disguised
Verbal Tics
- can be a series of simple sounds, animal sounds, words or phrases
- are often embarrassing and socially disabling.
- not all that common, but commonly thought of as tic disorders
- Simple sounds in combination, emitted in quick succession
- repetitious
- Animal sounds:
  - not common, but the most noticeable of verbal tics
  - present in younger children,
  - people often assume they are purposeful, even though they are not.
- Words:
  - may be associated with the more severe forms of tics
  - fewer than 20% of people with tics ever get verbal tics
  - sometimes involve slang
  - occur in children who have difficulty focusing, are hyperactive or have behavioural adjustment difficulties during a school day.
Complex tics
- Can be random tics put together
- may start to look very much like a habit or compulsion
- Some are hardly noticed; others can be embarrassing.
- Grooming tics:
  - involve hair twirling, pulling up socks, and straightening clothes.
  - Rarely disabling
  - often not noticed until they go away
- Sexual tics:
  - Touching one's privates briefly and the same way
  - making sexual symbols
  - Uncommon, but in younger children are thought by professionals to possibly indicate sexual abuse.

Occurrence in the general population of children

Tics vary in their incidence in the child population. In community groups, 1-13% of boys and 1-11% of girls have tics.
The more severe form of tics is found in about 3-5 children out of every 10,000.
Milder forms are much more common.
Recent studies show that 2.9 % of children aged 13-14 have severe tics.
Peak occurrence of tics is thought to be between 9-12 years.
Motor tics are the most common, and vocal ones are less common.

In this category one would find tics that are not very noticeable, occur infrequently, e.g., 3-4 times per hour, and do not interfere with the child's performance.
These may be simple habits that will eventually go away. Grooming ticks or tics that involve animal sounds would belong in this category.
They may also involve the arms and hands or the entire trunk, e.g., trunk twisting or thrusting of the hips.
Tics in this category may relate to the release of stress or for the purpose of soothing oneself under conditions of uncertainty or anxiety.
They may be seen as "bad habits" that will eventually go away.
They are more likely to be seen in children who are more fearful and nervous and attempt to adapt to the school setting.

Tics are more noticeable, more frequent than in the green light area, and involve all forms of expression described in the green light area (LINK pp. 1-3).
They may occur frequently, such as ten or more times per hour, and are more noticeable.
They may involve repeated eye rolling, eyebrow lifting, squinting, grimacing and pursing of the lips as well as head turning.
Vocal tics may begin to appear. Complex facial tics, involving frequent head turning and hair tossing, could also be seen. Simple sounds emitted by the child may also fall into this category.

It is cause for concern when you observe young children with tics that are frequent and quite noticeable, regardless of their location of expression in the body.
Tics that occur together such as motor and vocal tics occurring in combination are also of serious concern.
Tics are in the Red Light Zone if they interfere with the young child's ability to pay attention. They may occur more frequently in children who have already been identified as having a mental health problem.
Tics in this category may appear along with a significant change in the child's environment and family circumstances. In some instances the child may complain that the tics are painful and are completely out of his or her control.

In this age range it is unusual to see tics that occur frequently or last a long time. Tics that do occur are likely to appear no more than 3-4 times per hour and may be completely absent under conditions of relaxation.
Tics may involve the head or body and extremities and they may also be easy to disguise, so they are not easily noticed.
These tics are likely to appear when the child is anxious or stressed, and may be easy to control by the child of this age.
They may be simple facial tics, eye rolling, simple grimacing or repetition of certain sounds.

Tics begin to be worrisome when they are occurring frequently, are beginning to be noticed by others and are not likely to be suppressed by the child.
They may involve the head, the extremities or the entire trunk and they are likely to be fairly obvious to observe.
They may even begin to affect the child's performance at school and are likely to appear regardless of the child's state of mood and state of comfort.

Tics to really worry about and seek assistance for are those that are frequent, long lasting, and are clearly noticeable.
Complex tics, involving more than one muscle group, such as the trunk and the head or combinations that involve vocal and motor components, are very worrisome.
Such tics are likely to coexist with other mental health problems, such as difficulty in focusing, problems with self-control and developmental difficulties.
They are likely to be persistent, and may in fact worsen with time.

Simple, infrequent and barely noticeable tics are not a cause for concern. They perhaps appear for the first time at this stage, and are controllable by the youth.
They may involve grooming rituals, such as tossing of the head, rolling of the eyes, squinting, pursing of the lips, and twisting of the trunk.
It is unusual to hear sound repetition or repetition of words or animal sounds. Tics in this category will likely not last long and do not interfere with the child's functioning.

Teachers should pay attention when tics become more frequent, e.g., 10-14 times per hour, are likely to be noticeable and worrisome, and if the youth feels embarrassed about them.
There is less of an ability to suppress the tics, and the duration and intensity of the tics may be greater.
There may be the beginnings of complex tics that involve motor and vocal components, and the young person may also present the tics in the context of another mental health problem.
Because of the greater awareness, the youth may feel more uncomfortable about their tics and may ask for assistance.

It is of serious concern when tics are quite noticeable, frequent, intense and likely to interfere with the youth's activities at school as well as his or her functioning in the peer group.
The tics are unlikely to be suppressed voluntarily, and the youth may experience considerable distress as a result of the tics.
It is significant if the tics first began at a young age, and it is possible they could have started as early as 2 years of age.
Tics in this category are likely to be well organized and complex, and may be so problematic that they require immediate intervention.

Simple, infrequent and barely noticeable tics are not a cause for concern. They may appear for the first time at early adolescence and are controllable by the youth.
They may involve grooming rituals, such as tossing of the head, rolling of the eyes, squinting, pursing of the lips, and twisting of the trunk.
It is unusual to hear sound repetition or repetition of words or animal sounds. Tics in this category will likely not last long and do not interfere with the student's functioning.

Teachers should pay attention when:

Tics become more frequent, e.g., 10-14 times per hour
Tics are somewhat noticeable and worrisome
Because the tics are more noticeable, the youth may feel more uncomfortable or embarrassed about them and may ask for assistance
The youth is not always able to suppress the tics, which are becoming more frequent and intense
There may be the beginnings of complex tics that involve motor and vocal components
The young person may present the tics in the context of another mental health problem

It is of serious concern when:

Tics are quite noticeable, frequent, intense and likely to interfere with the youth's activities at school as well as his or her functioning in the peer group
The tics are unlikely to be suppressed voluntarily, and the youth may experience considerable distress as a result of the tics
Tics are well organized and complex, and may be so problematic that they require immediate intervention

It is significant if:

The tics first began at a young age, and it is possible they could have started as early as 2 years of age

What are some factors to consider about what may behind the actions? The beliefs that follow relate to all age groups. Back to top

Tics are thought to be inherited. For example, in twins, if one twin has tics, there is a 90% chance that the identical twin will have tics as well. There is a 30% chance that a non-identical twin will have tics.
If a parent has severe tics, about half the male children will have tics or obsessive or compulsive behaviours. Some of these 50% will have a severe tic problem themselves, some will have a chronic tic disorder and a small percent will have an obsessive or compulsive behaviour.
Female children are less likely to be affected. But more will have a tendency to engage in rituals and repetitious behaviours.
No special gene that is responsible for tics has been found so far. It is possible that many different genes may be responsible for tics.

Brain Involvement

There is a part of the brain that is thought to be responsible for taking information from our body and mind, putting it together and helping us to act. Any problem with this part of the brain affects the way people move, think or both. It is possible that this part of the brain is malfunctioning in children with tics.
Another possibility is that children with tics have different brain chemistry than other children.
Medications that affect the brain's levels of dopamine (a major brain lubricant) help to suppress tics. This finding suggests that some people's particular dopamine chemistry is contributing to their tics, but we still don't know what other chemicals may be involved.

Temperament

There does not seem to be any information as to the role of temperament for the presence of tics.
Children with low self control (low self-regulation) and immediate and impulsive reaction to events (high in reactivity) are more likely to be adversely affected by tics.

Children with overt disabilities, such as Down syndrome, or physical deformity are also more likely to be stressed and their tics may become exacerbated.
Children with covert disabilities, such as those who are picked on by others for being not as smart or competent, or believe they are not, are also more likely to tic as a result of the cumulative stress they experience.

The child's interpretation of what is happening to him or her will relate to how they react to the urge to tic.
Many other behaviours are associated with tics. Tics occur in:
- 50% - 90% of children problems in attention focusing or hyperactivity
- 30% of those who are involved with ritualistic behaviours and repetition
- 30% of those with depressed mood
- 30% of those with anxiety
- 50% to 80% of those with problems in accepting directions and authority
- 20% in those with behaviour problems.

Family adversity and stress, or a student’s poor nutrition, or neglect in the family, may affect the incidence and severity of tics. Students from such families may be more likely to be affected by tics, and the way the tics may appear more severe.

There is not enough information about how culture and ethnic background affects the presence of tics. However, people from different cultures may have a range of interpretations to observed tics.

Community Environment/Changes

Communities suffering major disorganization, such as famine, war or any other traumatic condition, are more likely to have children who tic.
Tics in such communities are more likely because of the association with conditions such as depression, anxiety, poor nutrition and care, poor sleep, and drug abuse.

Children who are exposed to parental strife related to chronic disagreement, separation or divorce are more likely to display tics because of the stress inherent in such conditions.
Very rarely, children who already displays tics, and whose parents are in conflict may show an exacerbation of tics as a result of "secondary gain". In other words, such children may use tics to emphasize their unhappiness and their need for the parents to get back together again.
Children who have been made fun off for ticking will also have an exacerbation of their tics.

Most authors emphasize that there is no cure for tics. No operation, medicine, substance or behaviour is likely to have tics go away permanently. However, there are efforts that may make their frequency or duration lower. Two main types of strategies are available: (a) Non-medical interventions and (b) Medical interventions.

Please note that there are no differences in the age of the children receiving the interventions mentioned below. Of course, recourse to medication is a doctor's responsibility and is more likely to be relevant to the older age group.

In class

It is important for the teacher to try to help all children feel at ease in the classroom. Express your feelings of care and the fact that you value each child. Children with tics may benefit from even more frequent positive interactions.
Refrain from mentioning the tics to other children in the classroom or mentioning the tics to the child.
Ensure that the child is not the target of either positive or negative remarks by other children.
If you notice the onset of tics, determine their severity and whether the parents have to be notified.

In school

If the tics are quite noticeable, the school principal and/or support team may be notified to ensure that the child is not bullied or upset by other children in the playground or gym.
Provide any support and facilitate any procedure that is prescribed for the child.

With family

Medical Attention

If tics are of concern and interfere with the child's functioning, ensure that the child is examined for tic severity but also for conditions that may co-exist with tics.

Sleep

Make certain that the child obtains adequate rest at night be sending him/her early to bed.

Nutrition

Ensure that the child is given a healthy diet, including fruits and vegetables.

Stress

Parents make every effort to reduce sources of stress and aggravation in their child.

In class

It is important for the teacher to try to help all children feel at ease in the classroom. Express your feelings of care and the fact that you value each child. Children with tics may benefit from even more frequent positive interactions.
Refrain from mentioning the tics to other children in the classroom or mentioning the tics to the child.
Ensure that the child is not the target of either positive or negative remarks by other children.
If you notice the onset of tics, determine their severity and whether the parents have to be notified.

In school

If the tics are quite noticeable, the school principal and/or support team may be notified to ensure that the child is not bullied or upset by other children in the playground or gym.
Provide any support and facilitate any procedure that is prescribed for the child.

With family

Medical Attention

If tics are of concern and interfere with the child's functioning, ensure that the child is examined for tic severity but also for conditions that may co-exist with tics.

Sleep

Make certain that the child obtains adequate rest at night be sending him/her early to bed.

Nutrition

Ensure that the child is given a healthy diet, including fruits and vegetables.

Stress

Parents make every effort to reduce sources of stress and aggravation in their child.

In class

It is important for the teacher to try to help all children feel at ease in the classroom. Express your feelings of care and the fact that you value each child. Children with tics may benefit from even more frequent positive interactions.
Refrain from mentioning the tics to other children in the classroom or mentioning the tics to the child.
Ensure that the child is not the target of either positive or negative remarks by other children.
If you notice the onset of tics, determine their severity and whether the parents have to be notified.

In school

If the tics are quite noticeable, the school principal and/or support team may be notified to ensure that the child is not bullied or upset by other children in the playground or gym.
Provide any support and facilitate any procedure that is prescribed for the child.

With family

Medical Attention

If tics are of concern and interfere with the child's functioning, ensure that the child is examined for tic severity but also for conditions that may co-exist with tics.

Sleep

Make certain that the child obtains adequate rest at night be sending him/her early to bed.

Nutrition

Ensure that the child is given a healthy diet, including fruits and vegetables.

Stress

Parents make every effort to reduce sources of stress and aggravation in their child.

In class

It is important for the teacher to try to help all children feel at ease in the classroom. Express your feelings of care and the fact that you value each child. Children with tics may benefit from even more frequent positive interactions.
Refrain from mentioning the tics to other children in the classroom or mentioning the tics to the child.
Ensure that the child is not the target of either positive or negative remarks by other children.
If you notice the onset of tics, determine their severity and whether the parents have to be notified.

In school

If the tics are quite noticeable, the school principal and/or support team may be notified to ensure that the child is not bullied or upset by other children in the playground or gym.
Provide any support and facilitate any procedure that is prescribed for the child.

With family

Medical Attention

If tics are of concern and interfere with the child's functioning, ensure that the child is examined for tic severity but also for conditions that may co-exist with tics.

Sleep

Make certain that the child obtains adequate rest at night be sending him/her early to bed.

Nutrition

Ensure that the child is given a healthy diet, including fruits and vegetables.

Stress

Parents make every effort to reduce sources of stress and aggravation in their child.

When it is determined that the tic is not severe, make no mention of it. The likelihood of the tic becoming severe is greater when more attention is paid to it. Back to top

If an adolescent indicates that the tic is troublesome and that they want to deal with it, discuss with them the options available. These include a visit to their family physician to help determine if there is a medical condition. It may also include providing them with written material about tic disorders. Back to top

When tics are this severe, do not wait for the adolescent to raise their concern. Identify a quiet time and private place to meet with the student. Tell them what you see and that you are concerned about how the tics are interfering with their academic progress, or with their social development, or both. Provide emotional support by telling them that you cannot imagine how difficult it is for them but that you would like to help them. Indicate that if their tics are heightened by stress then it will be necessary to identify ways for you to work together to reduce their stress.

Provide more time for the student to take written tests.
Provide alternatives if tics affect writing. Allow the student to use a computer, word processor, or typewriter to create assignments rather than handwriting them.
Provide a quiet place – position a seat where there is privacy and little distraction.
Allow for frequent rest periods when needed.
Allow the student to leave the room if he or she needs to let the tics occur in private.
Set a good example for accepting the student. It is important for teachers to discourage teasing by responding quickly and firmly whenever it occurs.
Provide extra tutoring, learning laboratories, or special classes if needed

Adolescents who have tics may or may not wish for their teacher to address their tic behaviour. The teacher must try to determine the maturity of the adolescent before determining whether to intervene, and if so, how.

Many adolescents are mature enough to be able to discuss their behaviour and what accommodations would be helpful for them. They must be treated with respect and maturity. For others, the teacher may be discussing the behaviour with the parents more so than with the adolescent.

Regardless, if the teacher is concerned about how the behaviour is interfering with the adolescent’s academic or social development, or both, they must address the behaviour.