Tics are quick, repetitive movements of any part of the body including the mouth and vocal cords. They are often described by people as “relatively involuntary” because these movements can often be suppressed but not indefinitely. Often people will feel the tic coming and be able to suppress it temporarily. Most of the time there is a physical or mental urge to complete the tic before it occurs. Tics usually first appear in the face, but not always. They often migrate and spread to other parts of the body and may come and go over time depending on physical and emotional stress.

There are 2 types of tics which can be classified into 4 main disorders. The two types of tics are simple and complex. Simple tics involve one or a few muscle groups and are very brief. Examples of simple tics include eye blinking, shoulder shrugging, grunting, throat clearing, etc. Complex tics, on the other hand, are much more integrated actions. These involve multiple muscle groups and can be very elaborate and in many cases extremely disruptive.

Tics that occur regularly for more than four weeks and up to one year fall into the type of disorder classified as transient tic disorder. Once tics have occurred persistently for one year we further classify the disorder as chronic motor tic disorder, chronic vocal tic disorder or Tourette’s disorder (also known as Tourette Syndrome). As the names suggest, chronic motor tic disorder involves only motor tics (ex: twitching, eye blinking, head bobbing, shoulder shrugging), and chronic vocal tic disorder includes purely vocal tics (ex: grunting, coughing, throat clearing). Vocal tics can also include more complex sounds such as yelling bad words (coprolalia), repeating words (echolalia), or randomly saying nonsense words (palilalia). However, these are much less common. Tourette’s disorder (which I will now call TD) by definition requires at minimum one year of both vocal and motor tics, although the vocal and motor tics do not need to be present at the same exact time.

Tic disorders usually begin between the ages of 2 and 15 years old. The average age when they begin is around 6 years of age. Often symptoms will worsen until around age 10 and then gradually improve. Usually symptoms improve a lot during adolescence. Sometimes, however, symptoms continue into adulthood and are much more chronic. We are not completely sure why, but boys are 3 times more likely to have a tic disorder than girls. Overall, TD affects about 1% of the population at any point in their lives. Studies have definitely shown that tic disorders can run in families and have a genetic component. But, other factors such as anxiety, premature birth, infections, and head injuries can also play a role in the development of tic disorders.

People who develop tic disorders are also at higher risk for other psychiatric conditions. Attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) are commonly diagnosed in people who have tic disorders. People with tic disorders are also more likely to have other anxiety disorders, aggressive behaviors, temper outbursts and social struggles. They may also be more prone to developing mood disorders such as depression if they experience bullying or shunning by peers. Occasionally, tic disorders occur suddenly after a bacterial infection. This is rare and controversial, but when it occurs there is typically a quick onset of tics, obsessions and compulsions following a streptococcal infection and is known as Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). Symptoms usually go away with antibiotic treatment for the underlying bacterial infection.

Management of tic disorders can depend a lot on how severe and disruptive the tics are for a person and the family. The goal of treatment for tic disorders is just to reduce the frequency or disruption of tics. Typically the only thing that really takes tics completely away is time. One treatment option is psychotherapy or talk therapy. Talk therapy is usually helpful for many reasons. Sometimes talking about the tics helps suppress the urge to tic. Keeping a log of things that make tics worse or better and discussing this with a therapist can be helpful in managing those things that worsen the tics and encouraging behaviors or activities that make them better. For people who experience urges to complete a tic, a form of therapy called cognitive behavioral therapy can help a person with a tic disorder manage how they respond to the urge to tic and think of alternative behaviors to reduce embarrassing or disruptive tics.

If the tics are disruptive to a person’s life and/or cause social issues, medications may be helpful. Two main classes of medications have been shown to be effective in making tics less frequent and less disruptive. Both types of medications have side effects and as always should be carefully considered with a physician before starting. The first type of medications is known as the antipsychotic medications, although we use them for more than just treating psychosis. These medications act on a chemical in the brain called dopamine. One particular drug in that class of medications, called pimozide, has been studied with positive results in tic disorders and has been given FDA approval for use in patients with TD. Examples of other antipsychotic drugs include risperidone and haloperidol. Another class of medications that we use is called the alpha-2 adrenergic agonists, which includes a drug called clonidine. These medications also affect dopamine in the brain but through a slightly different pathway. It’s important to talk with your physician about the risks and benefits of all treatments before starting a new medication.

The Tourette Syndrome Association has national and local chapters available and is a good resource for patients and families struggling with TD. For more information visit http://www.tsa-usa.org/index.html.

Children look to their parents for security, guidance, comfort. Braving the world and experiencing things for themselves can be a very scary thing. Separation anxiety is defined as excessive worry or fear experienced by a child when they are separated from a primary caregiver. This is a completely normal situation for infants and toddlers as they begin to explore new boundaries and test their independence. Separation anxiety is considered a normal developmental event between the ages of 6 months and 30 months. It is often at its worst between 13 and 18 months. You may see a toddler playing freely and suddenly running back to a caregiver for reassurance. They are testing their level of comfort with the world.

Usually separation anxiety declines significantly between 3-5 years as children are able to rationalize the reason why they are separated from a caregiver and begin to trust that mom or dad is will really come back to them eventually. Occasionally though, this normal decline in anxiety doesn’t occur. Occasionally separations cause more and more distress and are accompanied by worry that the separation will be forever. There may also be headaches, stomachaches, school refusal and even nightmares about separation. When it causes this much distress beyond about 3 years of age, we would classify that as separation anxiety disorder (SAD).

SAD affects about 3-5% of children and adolescents. It may be slightly more common in girls than boys. In reality, many kids suffer from symptoms of separation anxiety disorder but are never diagnosed because the symptoms aren’t disruptive enough to seek treatment. It typically peaks between the ages of 7 and 9 and is often associated with a stressful life event. One of the key features of SAD as opposed to other anxiety disorders is that children with SAD typically are very content when they are with their primary caregiver. The anxiety is usually only present when they are away from their parent. This is different from generalized anxiety disorder, which is a type of anxiety that lasts all the time regardless of who is nearby. Kids, though, who are diagnosed with SAD are also more likely to have generalized anxiety, specific phobias/fears, ADHD, fear of social situations and even oppositional defiant disorder which can make diagnosis of SAD a little trickier.

There are a lot of theories about how SAD develops. Children with SAD are often more shy and introverted than children without SAD which could lead them to be more uncomfortable with new situations and environments to begin with. Sometimes they tend to cling more to their parents in uncomfortable situations. There may be a history of something bad actually happening to a parent or the child such as a car accident, medical problem, burglary, etc. That can trigger a fear that something will happen again when they are separated. There is also a theory that early in the child’s life the bond between the parent and child is stressed. For instance, if the child spends a lot of time away from his primary caregiver because of an illness, work, foster care, etc. then the usual period of testing the boundaries may be disrupted and lead to insecurity.

There is a hereditary component to SAD. Parents of children with separation anxiety are more likely to have depression, panic attacks and other symptoms of anxiety. So, while anxiety can be hereditary, it can also be something that kids pick up just by being around anxious parents. Different parenting styles may also predispose kids to SAD. For instance, if a parent is hesitant to let their child explore the world it may lead the child to think that the world is unsafe. It’s important for parent s and kids to develop a balance between testing the world and keeping each other protected and safe.

Treatment of SAD depends on the severity of the anxiety. If it is caught early and is not too disruptive to daily life, beginning with therapy can be very effective. One type of therapy called cognitive behavioral therapy (CBT) is heavily researched and most recommended. CBT is a type of talk therapy that is based on the theory that our thoughts affect our emotions and behaviors. For instance, if you’re thinking about a lot of negative things you are more likely to feel down or angry. Or, if you are thinking about all the things that can go wrong you will probably feel more nervous, anxious and scared. CBT is effect in SAD by helping the child break the cycle between worrying about what will happened when they are separated from their caregiver, feeling anxious about the separation and staying near their caregiver.

In true CBT, the key is completing the homework assignments that the therapist gives the family. Assignments usually involve exposing the child to planned separations and giving them techniques to reduce the anxiety during the separations. It’s important for the child to face the very situation that they are worried about and to re-learn that their parent will come back to them. This can be very hard for parents to do as well because of fear that they are causing more anxiety for their child. We would typically start with very short separations and increase the amount of time slowly until they no longer feel anxiety during separation. This particular type of CBT is called exposure therapy. With time, the child experiences less and less anxiety because the cycle is broken when mom and dad keep coming back to them. They slowly stop worrying about what will happen when mom or dad are gone because they do come back.

If kids are really anxious or cannot tolerate the exposure therapy even for short periods of time, adding medication is recommended. The class of medications known as the SSRIs, such as Prozac, Celexa, and Zoloft, are usually the first-line medications. These can be helpful in reducing the overall level of anxiety and improving mood. This particular class of medication does not work overnight and have to be taken daily. Usually some benefits are seen within 2-3 weeks but the full effects are not seen for 4-6 weeks typically. The choice to add medications is very individual and is important to discuss with your physician.

Kids with separation anxiety disorder generally do very well with appropriate treatment. The earlier treatment is sought, the more easily the cycle of worrying can be broken. Most children recovery quickly and do not require long term treatment for the separation anxiety.