If the child has a tic

Frequent clearing of the throat, grunting, winking, barking or sniffling: tic disorders are chronic neuropsychiatric disorders that begin in childhood and are relatively common.

«Worldwide, around four to twelve per cent of all children between the ages of four and eleven are affected - boys are three to four and a half times more likely than girls,» says Friederike Tagwerker Gloor, psychologist and member of the special consultation for tic and obsessive-compulsive disorder at the Psychiatric University Hospital Zurich.

Typical characteristics of this disorder are so-called tics, which have an extreme range and can vary greatly from child to child, but also change over the course of the disorder.

Most tics go away on their own

«A tic is a short, involuntary, non-rhythmic muscle movement or sound that serves no recognisable purpose,» says Tagwerker Gloor. A distinction is made between motor tics such as blinking or throwing the head and vocal tics such as coughing, barking or clearing the throat. Motor and vocal tics can occur individually or in combination, be simple and inconspicuous or complex and disruptive, and vary greatly in frequency of occurrence.

However, the expert can often reassure worried parents: «The vast majority of tic disorders are temporary and go away on their own after a few weeks to months.» In three to four per cent of children, however, the symptoms persist for more than a year and are therefore considered chronic. Around one per cent of those affected show symptoms of Tourette's syndrome, the most severe form of tic disorder, in which motor and vocal tics occur permanently together, says Tagwerker Gloor.

The exact causes of tic disorders are still not fully understood.

Typically, the symptoms of chronic tic disorders continue to change into adulthood. «In most affected children, the severity of the tic disorder increases significantly between the ages of five and ten and decreases again at different rates after the age of twelve - regardless of treatment,» says the psychologist.

«As a result, chronic tic disorders usually improve by themselves into adulthood or even disappear completely.» However, if the symptoms persist into adulthood, spontaneous recovery, i.e. the phenomenon of self-healing without external therapy, is considered rather unlikely. This is usually the case with Tourette's syndrome.

Neurobiological factors suspected to be the main cause

The exact causes of tic disorders are still not fully understood. «In addition to various environmental factors, genetics play a major role,» emphasises specialist Florian Kraemer, who also works in the management team for tic and obsessive-compulsive disorder at the University Hospital Zurich. This means that the predisposition to develop a tic disorder is largely inherited and runs in families.

«We assume that suppressive systems in certain control circuits of the brain are disrupted in those affected, particularly in the basal ganglia, which regulate motor processes, among other things. Using imaging techniques, it was also possible to detect characteristic changes in the prefrontal brain - an area of the brain that is primarily responsible for planning and action as well as empathy and impulse control - in these people,» says Kraemer. There are indications that a disorder of the dopamine neurotransmitter system and the associated overactivity of this system are involved.

Stress and strong emotions can trigger tics

However, in the course of childhood development and the remodelling of brain structures during puberty, the body often seems to regulate these imbalances again. «This would also explain why childhood tic disorders often improve significantly or even disappear completely by the age of 22,» says the senior physician. «It also explains why stress and strong emotions, whether negative or positive, can trigger or significantly intensify tics.»

Typically, certain psychiatric conditions occur together with tic disorders. «Over 50 per cent of those affected also suffer from ADHD and obsessive-compulsive disorder, and we often also see stuttering, depression, impulse control disorders and autism spectrum disorders,» says Friederike Tagwerker Gloor. In many cases, the symptoms of the additional disorders are more of a burden on the children than the tic disorder itself. This is because simple tics usually don't bother those affected that much if they are not teased or hurt themselves because of them.

Parents are particularly worried

The situation is different with compulsions, which often cause a great deal of distress, or with ADHD, which causes problems at school in particular. Depending on the level of distress, the more stressful additional illnesses are prioritised accordingly. This is because when the compulsions or ADHD symptoms improve, the stress level usually also decreases, which in turn has a positive effect on the symptoms of the tic disorder.

The treatment of the tic disorder itself is therefore primarily based on the severity of the symptoms and the child's level of distress. «When affected families come to us, it's usually the parents who are most worried, worried about possible bullying or reproaching themselves because they feel they have done something wrong,» explains Tagwerker Gloor. «The affected children themselves, on the other hand, often show much less distress.»

If pressure is applied, the symptoms can intensify

As a first step, it is particularly important to provide comprehensive information about the illness. Detailed psychoeducation, as the explanation of the illness in layman's terms is also known, creates understanding and helps to take the pressure out of the situation.

«In milder cases, when the tics only have a minor impact on the child's school and everyday life, we usually advise them to wait and see,» says Tagwerker Gloor. «We also give families practical behavioural tips to help them deal better with the tic disorder in everyday life.»

Relaxation, distraction or concentration on a specific activity dampen the tic symptoms.

Friederike Tagwerker Gloor, psychologist

In the case of tic disorders, it is crucial to exert as little pressure as possible on the child, as stress can trigger the attacks and also exacerbates the symptoms. If a child displays tics, parents should therefore never ask their child to stop or even scold them. It is better to either «overlook» the behaviour or address it lovingly and offer targeted measures to alleviate it.

«This is because relaxation, concentration on a specific activity or even distraction have a demonstrably dampening effect on tic symptoms,» explains the child psychologist. «This means that there are usually significantly fewer or no tics during sleep, rest periods, sport and school.»

Inform school and neighbourhood at an early stage

In everyday life, parents can relieve their child in a specific tic situation by offering them something to drink or playing calming music, for example. Lying down, watching TV or stroking can also be helpful. «For older children, relaxation techniques such as children's yoga, progressive muscle relaxation or autogenic training have proven effective,» says Tagwerker Gloor.

«Exercise, sport, playing music or singing also have a positive effect.» Last but not least, the psychologist advises always informing the school and the immediate environment as early as possible so that they can also react appropriately.

Behavioural therapy reduces the severity of symptoms

These measures are not always enough. «If the tics increase in frequency and severity, children suffer because they are teased, school impairments occur or even health problems such as tension, we advise targeted treatment. Psychotherapy and medication are the main options here,» says the tic consultation expert.

In terms of psychotherapies, habit reversal training (HRT) and exposure with response prevention (ERP) have proven particularly effective. These two behavioural therapy methods cannot cure tic disorders. However, studies have shown that they help to reduce the severity of symptoms by over 30 per cent.

«In their implementation, both methods utilise the fact that those affected often experience an unpleasant premonitory feeling before performing the tics, which can be imagined as similar to the inner tingling before sneezing,» the child psychologist describes. «With HRT, the children learn to better perceive this premonition and then perform targeted movements in the opposite direction to the tic, which appear inconspicuous to the outside world.»

ERP is also intended to break the automatism that a tic must inevitably follow a premonition. «We can achieve very good and long-lasting success with these methods, particularly in the case of moderate tic disorders,» says Tagwerker Gloor. «However, the prerequisite for this is that the child is highly self-motivated and has sufficient patience, as the implementation in everyday life requires a lot of practice.»

Medication helps particularly quickly

If the necessary self-motivation is lacking or the tics are so severe that rapid symptom relief is required, medication can also be used. «Antipsychotics are used to treat tic and Tourette's disorders,» says paediatric psychiatrist Kraemer. «These are drugs that regulate the excess dopamine, which often reduces the tics by 50 to 95 per cent after just a few days.»

However, many parents have concerns about possible side effects. «Modern antipsychotics, such as those based on aripiprazole, have few side effects and are generally very well tolerated,» explains Kraemer. The medication can be administered in drop form, so that a particularly low and individually customised dosage is possible. In addition, regular follow-up checks are carried out before and during treatment.

Even medication only has a symptomatic effect and does not cure the disease. «However, they help to bridge the time until the child's brain metabolism functions have matured accordingly in the course of development,» explains the paediatrician. «The dosage can then often be significantly reduced after just one year or the medication can be discontinued completely without the symptoms increasing again.»