QUESTION
Our eldest son is nearly eight years old. In the past couple of years he has developed several motor and vocal tics, and we are unsure how to help him deal with them. Up to last year we mostly ignored them and reassured him they would go away. However, he began to become more aware of them and they were bothering him, so we brought him to see a psychiatrist privately who confirmed he has mixed motor tics – but not Tourette’s syndrome – and said he thought they would fade as he got older.
Since then he has developed a repetitive tic that involves counting and symmetry. For example, if he touches something, he feels the need to touch it twice, or if he jumps to one side, he will have to jump to the other side. Sometimes he has to say things twice too. For a while the tics were not really affecting his life; it was happening only three or four times a day. But now they are increasing in frequency, and he is frustrated and upset by them.
He doesn’t seem to be upset or anxious about anything in particular so I’m not sure why it’s getting worse. He is well behaved and does well at school, although he’s quite shy. However, he can be very disruptive and challenging at home, with regular outbursts and tantrums. In between these flare-ups, he is a happy-go-lucky, loving and funny little boy. We are worried for him, even though we never let him know that, so we’d love to know if there are any strategies we can use to help.
ANSWER
It sounds as if your son is experiencing a number of different compulsive symptoms, whether these are the motor and vocal tics he experienced previously or his more recent behaviours of having to jump to one side or having to touch or say things twice.
These more recent behaviours sound more like obsessive compulsive symptoms, though it is common for children who have motor and vocal tics to have some obsessive-compulsive and other anxiety symptoms as well. It is also common for certain tics or repetitive behaviours to change and to be replaced by others.
As the psychiatrist you attended said, for most children these behaviours tend to fade over time and only a small subset of children get diagnosed with a formal disorder such as Tourette’s syndrome or obsessive compulsive disorder.
Generally, the best tactic is to ignore these behaviours when they happen, or to distract your child gently and positively, without drawing too much attention to the behaviour. However, if your son is becoming bothered by the symptoms or if you feel they are interfering with his life, then it can be helpful to teach him some coping strategies.
Listen carefully when your son talks about the symptoms. Some young children aren’t aware of their tics or compulsive behaviours or, if they are aware, they can be very defensive or sensitive talking about them. Even though he is expressing frustration, it is a good sign that your son is already talking to you about the behaviours, as this means he is open to your support and help.
When he discusses what is going on for him, always be empathic and supportive. A good strategy is to talk of the tics or compulsions as being external to him. For example, you might want to agree a name for them that makes sense to him, which could be the formal name, “the tics”, or simply “the habits” and then refer to them as something interfering in his life that he is working to overcome with your support: “Those awful tics can be a pain. Let’s look at how we can keep them from bothering you.” An upbeat positive tone can help.
Habit-reversal therapy
There are a number of strategies that can be helpful in managing tics and compulsive behaviours. For example, habit-reversal therapy centres on helping the child become aware of his urge/physical tension just before a tic happens and then to choose to do a different physical behaviour that might break the pattern and release the tension just as well. For example, instead of rubbing his face with his hands, a child might squeeze his fists or sit on his hands instead. Brainstorm with your son different behaviours he might like to try. It can be a good idea to rehearse these behaviours, but make sure the practice is kept light and fun.
Mindfulness
A second strategy is to help your son be mindful: to notice the strong urges or obsessive feelings that happen before a repetitive behaviour and to stay with these feelings without acting, watching them dissipate of their own accord.
For example, instead of jumping to one side when he touches something, you can help your son be mindful of his urge and then learn to relax in the moment. Over time, your son might learn that these feelings will reduce of their own accord without the ritual of jumping. You can practise this mindfulness with your son by doing fun exercises such as mindfully noticing sensations in the body or counting breaths. You could even take him to a child and adult yoga class that focuses on these skills, and learn the skills together.
Teaching behavioural strategies
Learning the tactics above can be difficult to teach a young child who might be distracted by lots of different things. The key is to make the learning fun and child-centred and to take a step back if he feels pressured in any way.
There are lots of good resources and tip sheets online and some places to start are at worrywisekids.org or aboutourkids.org.
Alternatively, you may wish to seek the help of a mental health professional such as a behavioural or occupational therapist or a psychologist who is experienced in working with children with these symptoms. Contact the psychiatrist you went to before if your son’s symptoms don’t improve or if they worsen over time.
Dr. John Sharry, Irish Times Newspaper, June 2014. John writes in The Irish Times Health+Family every Tuesday.