Tics

My ten-year-old has started squinching his eyes and scrunching his shoulders. My best friend says it’s probably a tick, but he hasn’t been out in the woods or anything. What could it be?

Ah, the English language—purported to be the most difficult to learn in all the world. Consider the confusion of someone trying to differentiate between a “homophone” and a “homonym?” You can list a bunch of homophones: to, too, two; so, sew; be, bee; principals, principles. Can be fun, but confusing. Homonyms might be even worse. The spellings the same, but how do you know which meaning is intended? Bark, bolt, nails, pool, mine. It’s true in medicine as well. Vein or vain? Heal or heel? Die or dye? Muscle or mussel? Jugular or juggler? Gotta get these straight. That’s tough, and it was a homonym that almost did one of us in. He will go nameless, but he spent more than twenty-five years in the ER and should have known better.

On a Saturday night in the distant past, this ER doc found himself in a busy emergency department being swamped by a never-ending rush of patients. He decided to take things in hand and went out into the waiting area (always a mistake), and with clip-board in hand, began triaging a row of seated patients. He came to a young man, sitting cross-legged and clutching a dishtowel to his lower leg.

“What happened?” queried the doctor.

“Got hit by a bat,” was the terse response.

A scribbled note, passed on to the unit secretary, and within minutes the young patient was taken around the corner to radiology for x-rays of his lower leg. A baseball bat can do a lot of damage.

Thirty minutes later, one of the radiology techs called the ER doc and asked, “Are you sure you want an x-ray of this man’s leg?”

“Of course,” was the impatient response. “He got hit by a bat.”

A pause, and then, “Doctor, you know he got hit by a flying bat. The vampire kind. Skin’s not broken or anything.”

Another pause, and then, “Go ahead and cancel that. I’ll find out who ordered it.”

Again, that was a long time ago, and learning took place. The point was never forgotten, and a constant reminder that we have to pay attention to our words. The same is true here. This mother’s best friend suggested the presence of a “tic,” not a “tick,” and she’s probably right. This is something we need to know about and try to understand.

“Tics” are intermittent, repeated movements that are usually specific to the individual child. We can classify them as being “simple,” such as head jerking, blinking, facial grimacing, or shoulder shrugging, or “complex”—kicking, jumping, a bizarre gait, or strange body gyrations. The majority of tics fall into the “simple” category and are transient—meaning that they last less than one year. They’re very common (as many as 1 in 10 normal children may be affected), and if truth be told, many of us have experienced this problem ourselves. That might be a blessing, since we’ll have insight into what’s going on with our child and be able to share our own experiences with them.

Aren’t these voluntary? I mean, doesn’t my child cause them to happen? Can’t they control this?

Not exactly. Most experts would describe simple tics as being semi-voluntary or “unvoluntary,” but not voluntary. Is that clear enough? Hmm. The reason for this less-than-clear explanation is that your child may sense an urge to perform his tic (blinking four times as an example) and be able to suppress it, but only for a brief time. The blinking will occur, followed by a sense of relief. Then the clock resets. We call it simple, but it’s not. Here are some things we know about “simple tics”:

• They can frequently start before the age of 3 years
• As above, they can be temporarily suppressed, but only temporarily (this is important regarding treatment)
• They decrease when your child is focused on something and increase with stress, anxiety, and fatigue (another important treatment point)
• They don’t occur during sleep
• The presence of other conditions is common—the most frequent being Obsessive Compulsive Disorder (OCD), ADHD, and anxiety
• They are preceded by an identifiable “urge” or sensation (another help with treatment)

So how can I help my child?

There are some things we can do, starting with understanding the problem and then exercising patience. That’s going to be key. Patience. We’re going to focus on the approach to simple tics, since those more complex (Tourette’s Syndrome is one) need to be addressed by trained and experienced counselors. Here’s what we recommend:

• Take a look at the Yale Global Tic Severity Scale (YGTSS) or the Premonitory Urge for Tics Scale (PUTS). They’re not nearly as intimidating as they sound, and will provide information and a way to assess the significance and severity of your child’s tic. Understanding comes first.
• Make it your goal to not confront or threaten/intimidate your child when you notice the tic. They can’t help it.
• Insure that your child is getting adequate and good-quality sleep.
• Try to identify causes of stress and deal with them.
• Educate other family members about this condition and about your plans for intervention.
• Talk with your child openly, but don’t draw excessive attention to the tic. Be positive. “We’re going to work through this.”
• If your child is old enough, try to identify their “trigger feelings.” What do they feel/sense before the onset of the tic? Can they name it?

With these points in mind, we can develop a strategy to help our child. This is going to initially be based on “behavior therapy.” If you’ve identified the “trigger” or warning sign, have a plan of action—deep breathing when this happens, or focused attention on some other activity (clenching and unclenching a fist with the hand in their pocket). This is a form of something called “habit reversal therapy” (HRT) which involves three components—awareness training, competing response training, and social support. You might be able to do this at home, but a more formal intervention might be available with trained therapists. Give it a try, and again, be patient.

If behavior therapy is not successful, there are some medications that have proven to be of benefit, but have some bothersome side effects. This would be a last result, and seldom needed with simple tics. Remember, these usually go away within a year, most within a few weeks or months. If your physician immediately reaches for a prescription pad, call a time-out. And remember, it’s a “tic” not a “tick.”

Sew, weather ewe ever sea won of these, keep it inn mined. Bee aware of watt it looks like, no wen two get help, and remember you herd and red about it hear.

…

This is an excerpt from the new book I’m writing with pediatrician Dr. Robert Alexander. The book will address 100 questions from parents regarding their children’s health. Feel free to email us with questions: askthedox@yahoo.com