For parents/carers

The clinic provides a comprehensive mental health assessment of children and young people with complex tics between 3 and 17 years of age. Young people are most often referred to the Tics Service if they have additional co-occurring difficulties, and where there is a question about the diagnosis, or if advice on the child’s treatment is required.

Tics are fast, repetitive muscle movements that result in sudden and difficult-to-control body movements (e.g., eye blinking, shoulder shrugging) or sounds (e.g., sniffing, throat clearing, involuntary sounds). Tics are common in children of primary school age – for most young people they are harmless and do not require specialist assessment.

Tourette syndrome is a neurodevelopmental condition characterised by motor (body) and vocal (sound) tics. Tics usually begin in childhood and if they persist longer than a year a child could be diagnosed with Tourette syndrome. The condition is referred to as 'a syndrome' due to the frequency with which conditions such as attention deficit hyperactivity disorder and anxiety disorders co-occur.

There are no specific tests used to diagnose Tourette syndrome. Diagnosis is made through observation and history taking. There are some standards for diagnosing Tourette syndrome, agreed internationally, as follows:

A child or young person must:

• have multiple motor, and one or more vocal tics that happen regularly, although not necessarily at the same time
• have tics occurring many times a day, or on and off, for longer than one year
• be younger than 18 years old
• not have any other conditions that could cause the tics

Although there is some discussion about these standards, most doctors use them as a guide for diagnosing TS.

TS was first described in the 19th Century by a neurologist, George Gilles de la Tourette, after whom the condition is named. The symptoms can range from mild to severe. Worldwide, Tourette syndrome is thought to affect about one per cent of the population. Tics affect more boys than girls, and we do not yet know why this is the case. Tourette syndrome affects people from all races and ethnic groups equally.

TS is associated with other conditions:

• Attention deficit hyperactivity disorder (ADHD)
• Autism spectrum disorder (ASD)
• Obsessive compulsive disorder (OCD) and other anxiety disorders
• anger or rage attacks
• functional tics/Functional tic-like behaviours (discussed later)
• learning disorders such as dyslexia or dysgraphia
• low mood

We routinely screen for these additional difficulties as part of an assessment with our team as these often have a greater impact on the child’s life than the tics themselves.

Many young people with tics may not need to see a health professional or require specific treatment for their tics. However, for those who are seeking this support, a detailed assessment guides the clinician in understanding what the child’s concerns are and how they should be treated. As tic disorders are experienced on a spectrum of severity, there is no ‘one size fits all’ assessment or treatment for children and young people with tics.

The first intervention is usually learning about tics, which professionals refer to as ‘psychoeducation’.

View our Tourette syndrome information pack.

Once the young person, their family, friends and school understand about Tourette syndrome, they can often cope well, and no specific treatments may be needed.

If tics are having a significant impact on a young person’s life, and the young person is bothered by their tics and motivated, behavioural therapies such as Exposure and Response Prevention and Habit Reversal Training may be helpful in treatment. Evidence-based talking therapy such as cognitive behavioural therapy, delivered to address co-occurring difficulties which may impact on tics, can also be helpful. Psychological approaches can also help family members to cope better with the stresses that supporting a person with TS can bring.

Some of the difficulties in Tourette syndrome can be helped with medicines. These include the tics themselves, ADHD, OCD, anxiety and sometimes depression. The combination of medicines varies from person to person. More information about these medicines is available in our other information sheets. These can be found in the ‘helpful resources’ tab.

Visit the NHS website for more information on tics.

Functional tics are involuntary physical movements which may appear similar to the tics that people with Tourette syndrome have. However, the course and cause of functional tics is different from Tourette syndrome. Functional tics are often driven by anxiety and are more common in teenage girls than boys. A high proportion of the young people assessed within the Tic Disorder Service with functional tics also have undiagnosed neurodevelopmental conditions such as Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD).

ASD and ADHD can increase anxiety, particularly if undiagnosed. It is well known that symptoms of ASD and ADHD in girls are more likely to be missed by their parent/carers, teachers, and clinicians than boys with the same conditions.

A young person can have both tics seen in Tourette syndrome and other persistent tic disorders and functional tics, but it is important to get an accurate diagnosis as this will help guide the most effective treatment.

The first step in helping functional tics is to understand the nature of the tics and treat the anxiety symptoms that are thought to have triggered functional tics for the young person.

Hear our specialist team of psychologists and psychiatrists discuss functional tics in more detail. Use these links to jump to specific questions:

• What are the differences between Tourette syndrome, classic tics and functional tics?
• What types of tics do we treat at GOSH?
• What did your team observe over the COVID-19 pandemic?
• What explanation is there for the surge in functional tic presentation during COVID-19?
• What treatments are best for people with functional tic presentations?
• Where can people go for support and treatment for functional tics?

The first time you and your child meet our team will be for an initial assessment. The initial assessment is carried out with members of our team to gain a full understanding of what the current challenges are for your child, and to screen for any neurodevelopmental or mental health difficulties. We are also interested in the strengths that your child has and to learns about the many aspects of their lives that protect them against the difficulties that they face.

Prior to your child’s assessment, we will send you a questionnaire to complete online. During the assessment, a detailed interview will be carried out led by Psychiatrists, Psychologists, and other members of our team. As we work closely with your child’s local community services, we may invite external professionals from your local team to join the assessment, particularly where tics are presenting as one part of a picture of broader mental health challenge.

Once the assessment is complete, we will write a detailed report describing the assessment and recommendations which will be sent to your child’s referring team and their GP. We will discuss our recommendations with you before the end of the initial assessment and you will be able to ask our team and hopefully your local specialist team questions about these recommendations at the meeting.

We provide a ‘stepped care’ approach to treatment, meaning that your child’s treatment will be matched to their needs. We aim to offer all interventions in collaboration with your child’s local child and adolescent mental health team (CAMHS). Depending on the specific needs identified at the assessment, interventions may include a range of therapeutic approaches and/or medication, if appropriate. Where there are concerns regarding the risk and safety of a child, the child will be referred back to their referring team to monitor and manage. Unfortunately, our service is unable to provide emergency support to families, and this remains the responsibility of local services: GP/CAMHS/A&E.

Interventions that may be provided will be evidence-based, short and intensive to achieve the maximum effect and will be tailored to your child’s needs.

The Tics Service currently offers the following interventions if indicated following the assessment:

1. Group psychoeducation session on tics and Tourette syndrome to learn about living with the conditions
2. Group psychoeducation session on tic attacks, functional tics and tic-like movements to understand more about the conditions and how to cope with them
3. Behavioural therapies for young people with tics using Exposure and Response Prevention (ERP) or Habit Reversal Therapy (HRT); we deliver the treatments within a group or individually, depending on the young person’s needs and preference
4. Medication recommendations made to your local treating team
5. Cognitive assessments to understand a child’s learning strengths and challenges and whether they might have a diagnosable learning disorder / intellectual disability, which impacts on their quality of life or how they access treatment for their tics
6. Specialist follow-on assessments such as assessments for Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD) where judged to be a clinical priority in the management of tics
7. School consultation: to discuss strategies to best support young people with tics in the classroom