Tics: Why "Stop Doing That" Makes It Worse

It started with the blinking. Then the blinking stopped and it became a throat-clear, or a shoulder shrug, or a sniff, and it happens most when your child is tired or excited or has just been told to stop.

You have almost certainly been told to ignore it, and also to make him stop, by the same people on the same day.

What a tic actually is

A tic is a sudden, repeated movement or sound. Motor tics — blinking, grimacing, shrugging, head jerks. Vocal tics — sniffing, throat-clearing, grunting, repeated words.

The feature that matters most is one children can describe if you ask them properly, and adults almost never do. Most tics are preceded by an urge — a build-up of pressure or discomfort that the tic relieves, like the feeling before a sneeze or the need to scratch an itch you have been told not to scratch.

That is why "just stop it" is not a small unkindness but a technical error. Your child can hold a tic in, often for a surprisingly long time. What they cannot do is make the urge go away, and holding it takes so much attention that nothing else — the lesson, the conversation, the homework — is getting through.

How common, and what happens next

Simple, short-lived tics are very common in childhood. Tourette syndrome, which requires multiple motor tics plus at least one vocal tic over time, is much rarer: a systematic review and meta-analysis of 30 studies put the global prevalence at 0.5% (95% CI 0.3–0.8%), rising to 0.7% among children and adolescents.

The course is the part families most need and least often get. A prospective cohort followed 46 children with Tourette syndrome assessed before age 14 and re-interviewed on average 7.6 years later:

• 85% reported a reduction in tics during adolescence.
• The average age at worst-ever tic severity was 10.6 years — so for many children, the point at which parents panic is close to the peak.
• The only childhood measure that predicted worse tics later was how severe the tics already were.
• 41% experienced at least moderate obsessive-compulsive symptoms at some point, peaking roughly two years after worst-ever tics — and OCD symptoms were more likely to persist than the tics themselves.

Two practical conclusions. Most children get better, and the age you are most frightened is often the worst it will be. And the thing worth watching for is not the tic — it is what may arrive two years later. See OCD in children.

The century-long mistake

This is the part we would most like a Pakistani parent to know, because the wrong version is still being repeated here by people who trained a long time ago.

An evidence-based review in the Journal of Child and Adolescent Psychopharmacology states it plainly: for close to a century, behavioural interventions for tics were incorrectly considered ineffective and dangerous by the professional community — largely because of unfounded fears that suppressing tics would cause symptom substitution or a rebound of worse tics.

Those fears were not supported. Research went the other way, and a treatment was built on it.

CBIT — the first-line treatment

Comprehensive Behavioural Intervention for Tics combines two things: habit reversal training, which works on the urge-to-tic relationship by teaching a competing response the child performs when the urge arrives, and a functional intervention that identifies and neutralises the situations making tics worse.

It is supported by two large randomised controlled trials involving 248 people aged 8 to 69, and on that basis it has been designated a first-line treatment for tics by the American Academy of Neurology and the European and Canadian medical academies. It works alone or alongside medication, in person or by telehealth, and with or without the conditions that commonly accompany tics.

Two honest caveats. It is effective for approximately half of patients — real, not miraculous. And it needs a trained therapist, which is the actual bottleneck here rather than any doubt about whether it works.

The reason we labour the point: a great many families in Pakistan are offered medication first and behavioural treatment never. Knowing that CBIT exists and is first-line internationally is the thing that lets you ask for it.

What to do at home

1. Stop telling them to stop. Every reminder adds attention and anxiety, both of which increase tics, and none of it touches the urge.
2. Do not let anyone else comment either — siblings, grandparents, cousins. One conversation with the household is worth more than a hundred with the child.
3. Take the pressure off at the peak times. Tics rise with tiredness, excitement, stress and being watched. If they explode at homework time, the homework arrangement is the thing to change.
4. Let them tic freely somewhere. A child holding tics in all day at school will release them the moment they get home, often spectacularly. That is not deterioration; it is the bill arriving.
5. Talk to the school. A child who can leave the room briefly without asking, and who is not being marked down for disruption, does better. Teachers usually help once they understand it is not deliberate.
6. Ask about the urge. "Does it feel like something builds up first?" Most children have never been asked, and it is the foundation everything in CBIT is built on.
7. Watch sleep. Tiredness is one of the most reliable amplifiers — see helping your child sleep better.

What not to do

• Do not punish a tic. It is not a behaviour your child chose, and shame reliably makes tics worse.
• Do not imitate or joke about it, however affectionately.
• Do not chase every new tic. Tics wax, wane and change — one disappearing and another appearing is the normal pattern, not a deterioration.
• Do not accept "he will grow out of it" as a reason to do nothing when the tics are hurting or humiliating him. Most children do improve. That is not an argument for leaving a child to suffer through the worst two years unsupported.
• Do not assume the tic is the main problem. Very often the attention difficulties, the anxiety or the obsessive-compulsive symptoms alongside it affect life more.

When to see a doctor

• Tics that cause pain or injury — violent head or neck movements especially
• Tics that are stopping school, friendships or sleep
• A sudden, dramatic onset of severe tics in a child who had none, particularly after an illness
• Tics with weakness, loss of coordination or loss of skills
• Obsessive or compulsive symptoms — rituals, checking, needing things "just right" — given how often these follow tics
• Attention difficulties that are affecting learning
• Your child is being bullied, or has begun avoiding people — see when your child is being bullied
• Any movement that cannot be interrupted at all, or comes with a blank stare or loss of awareness — see absence seizures and inattention

Where we fit

Diagnosis of a tic disorder, and any decision about medication, is a doctor's job.

Ours is the behavioural side — the part that is first-line internationally and hardest to find here: working with the urge rather than the movement, changing the situations that amplify tics, getting the school on side, and treating the anxiety and attention difficulties that so often matter more than the tic itself. Our tics and Tourette syndrome page covers what assessment involves, and helping an anxious child covers what frequently sits alongside.

A consultation is Rs 1,500 and lasts up to 50 minutes, we work in Urdu or English, and you do not need a referral.

Sources

• Kohler A, et al. Description, implementation, and efficacy of the Comprehensive Behavioral Intervention for Tics as first-line treatment for Tourette and other tic disorders. Journal of Child and Adolescent Psychopharmacology. PubMed 39311713
• Jafari F, et al. Systematic review and meta-analysis of Tourette syndrome prevalence; 1986 to 2022. Pediatric Neurology. PubMed 36182698
• Bloch MH, Peterson BS, Scahill L, et al. Adulthood outcome of tic and obsessive-compulsive symptom severity in children with Tourette syndrome. Archives of Pediatrics & Adolescent Medicine. PubMed 16389213
• Conelea CA, et al. The CBIT + TMS trial: study protocol for a two-phase randomized controlled trial testing neuromodulation to augment behavior therapy for youth with chronic tics. Trials. PubMed 37400828