My nine-year-old’s record for clearing her throat is 33 times in one minute. I counted. It’s a noise so distracting sometimes you can’t really do anything else but count how many times it happens.
This has been happening, off and on, since she was six. At first, my wife and I thought it was allergies or a sinus infection. She eats a lot of dairy, so mucous was a plausible culprit, except it would happen at the strangest times: first thing in the morning, before she had eaten; while she was eating; as she was settling down in bed for the night.
We asked our paediatrician and she offered one of two explanations: it could be allergies, but it was more likely a behavioural tic. She explained that one of her own children had one and it would come and go during times of stress. She suggested allergy meds for a few weeks, just in case, but it became clear quite quickly we were dealing with a tic.
What are tic disorders?
Tics fall under the umbrella of Tourette syndrome. Modern medicine defines them as involuntary, repeated motions or sounds, which can include eye-blinking, mouth-twitching, nose-wrinkling, sniffing, throat-clearing, coughing, and grunting.
More common in boys than girls, it could be a release or coping mechanism related to attention deficit hyperactivity disorder (ADHD) or anxiety. According to the Tourette Association of America, the tic might feed a routine or ritual related to obsessive-compulsive disorder (OCD).
Tics are diagnosed based on their duration. Children who have tics that come and go are generally diagnosed with provisional (or transient) tic disorder. These tics typically resolve themselves within a year. Doctors also look at the period of time where the child experiences the tic; if there is no break over any three-month period, it’s considered a persistent (or chronic) motor or vocal tic, according to Dr. Jerry Bubrick, Ph.D., a clinical psychologist for the Child Mind Institute in New York City.
“The only difference between chronic motor or vocal tic disorder and Tourette Syndrome is that TS has kids with both motor and vocal tics at the same time,” says Bubrick, who treats tics through the Institute’s Anxiety Disorders Centre.
In the Paventi household, it’s a series of guttural throat-clears, punctuated by a cough, none of which serves any physiological purpose.
Diagnosing and treating tic disorders
One of the issues for us was determining when throat-clearing and coughing became more than just the possibility of allergies. It went on for most of the winter and spring before we brought it up to the doctor. In our case, we misjudged the cough and throat-clear as allergies to dust, pollen and all of the other things we were allergic to as kids.
Parents who suspect a tic should consult their paediatrician, especially if the child has already been diagnosed with OCD, ADHD or anxiety, as changes to the child’s therapy may be needed.
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A child with just a motor or vocal tic occurring for less than one year may receive the diagnosis of provisional tic disorder. And Bubrick says that ticking, like yawning, is suggestible. Adults should ignore the tic when dealing with children, as addressing it can make things worse, but monitor the tic to determine its frequency and any potential triggers.
If the tic lasts longer than one year, the diagnosis is updated to persistent tic disorder. At that point, Bubrick advocates for a type of cognitive behavioural therapy called comprehensive behavioural intervention for tics (CBIT). It’s a highly intensive 8- to 12-week treatment administered by a behavioural specialist certified in the practice—generally a psychologist, behavioural or occupational therapist, or social worker.
CBIT begins with building awareness for the tic with the child, as most aren’t aware of the tic or its extent. The idea is for the child to see what happens before the tic actually occurs and intervene—without causing further anxiety or embarrassing them, which could exacerbate the situation.
“We have them look in a mirror while they are experiencing a tic and we might discuss whether they noticed it,” he said. “Then we will ask them to raise their hand the next time they notice a tic coming.
Bubrick said the goal is to find where the urge to tic begins. If the tic is an eye blink, but before that they roll their shoulders, then he focuses on what causes the shoulder roll.
Once awareness is established, doctors try to understand the tic’s process. The first place to look is the cause of stress and anxiety.
“Tics and stress are kind of best friends,” Bubrick said. “So the more stressed out a child is, the more likely he or she is going to have a tic. If you know you’re really stressed out because of maths class, you’re probably going to have more tics there than you would in science class where you feel more comfortable or confident.”
With awareness built, Bubrick moves into relaxation therapies because a calmer body and mind are less likely to tic.
“No one is ticking when they’re sleeping,” Bubrick said. “When your body is completely relaxed, you don’t tic. The more stressed out your body is, the more likely it’s going to tic. If you’re sitting in class and you’re stressed, then you’re tensing your muscles and that’s not going to help you.”
Relaxation therapy involves a combination of deep breathing, guided meditation and a therapy called progressive muscle relaxation, which involves a tightening of muscles and relaxing them so the child learns the difference between being tense and loose.
The final phase of the CBIT treatment involves offering a competing response, sort of like how people trying to quit smoking will suck on lollipops to mimic the physical motion of bringing a cigarette to and from their mouths.
Bubrick used the example of a child who might press down hard on their eyes and keep them closed tightly as if they are watching a scary movie.
“The competing response would be to have them use those same muscles in their eyelids, but in the opposite motion,” he says. “They would open their eyes widely instead until the urge passes. And once the urge passes, they can bring their eyes back to normal and then move on.”
He says it sounds simple, but requires a lot of practice, patience and awareness among the parents and other adults around the child.
How to keep from losing your damned mind
The Tourette Association of America, tells parents they don’t have to be perfect when dealing with a tic. They just have to be aware of their own patience levels. It’s an important thing to keep in mind after experiencing a stressful day of your own and having to deal with a tic you cannot control.
I asked Bubrick what to do when my daughter’s tic begins wearing on my nerves. He reminded me the tic was not about me or something she was trying to do to me.
“She’s doing the very best she can to control a neurological condition that’s hard for her to,” he said. “So that might mean you getting some alone time and calming yourself down after a long day, getting yourself grounded and back to a neutral place. Or even doing something together, like taking a walk, where both of you can get relaxed.”