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My child has tics that have increased since the beginning of lockdown: what can I do?

Dr. A. Hubert, Pr R. Delorme (child psychiatrists) - Competence Centre for Chronic Tics Disease - Tourette's Syndrome - Centre of Excellence for Neurodevelopmental Disorders, InovAND, Robert Debré Hospital, Paris; Dr. A. Hartmann, Reference Centre for Tourette's Syndrome - Pitié-Salpêtrière Hospital, Paris;

O. Marechal and A. Romarin- French Association for Tourette's Syndrome (AFSGT)

One of the consequences of the pandemic caused by Covid 19 was the containment of the population. This may lead to an exacerbation of tics in your child.

What are tics?

- Tics are involuntary, sometimes conscious, brief, repetitive, aimless, non-rhythmic.

- Tics can be 'motor' if they produce movement or 'vocal' if they produce a sound.

- Tics tend to occur in bursts. For example: a child with a blink will present a burst of blinks and not a simple wink.

- The most frequent ones are tics of the eyes, mouth and neck; at the vocal level, tics are most often grunts, small cries, bird noises, sniffles or clearing one’s throat.

Be careful! Having tics isn't biting your nails or playing with your hair. Nor should tics be confused with obsessive-compulsive symptoms in OCD: with OCD, a ritual (gestures or counting) must be performed to reduce the anxiety linked to an idea (obsession), such as the fear that an accident will happen to someone close to you or the fear of being contaminated, for example.

Tics disorder: transient or chronic tics

- If the tics have been present for less than a year, then they are called transient tics.

- If the tics have been present for more than a year, then they’re chronic tics (either motor or vocal). When these motor and vocal tics are present simultaneously, we speak of Tourette's syndrome.

# Tics are quite frequent: they affect boys more than girls and 15 to 25% of school-age children with transient tics. For chronic tics and GTS, they diminish or even disappear in 75% of cases at the end of adolescence. Tics most often begin around the age of 5-7 years. They are most often beaded, i.e. they appear gradually.

# Tics can fluctuate over time (with more intense days, weeks or months) and a fairly frequent alternation of motor tics and then vocal tics. Their intensity is often increased in situations of stress or fatigue but also during positive emotions such as joy. Conversely, tics can decrease when the child is very concentrated, for example at school or when he does an activity that requires a lot of attentional effort (cycling, reading or writing).

# Tics are sometimes conscious, i.e. the child perceives that his or her tics are going to happen. He perceives a sense of tension in certain parts of his body before the tic happens, sometimes a tingling, or an itch. These are called prodromal/ premonitory sensations.

Be careful, if the tics appear suddenly during the Covid 19 phase and they appear almost at the same time as the fever (temperature above 38°C), or after a head trauma (frequent in the agitation of confinement) or if the tics appear with signs of altered consciousness or unusual behavior, then consult your general practitioner or paediatrician. Do not diagnose tic symptoms yourself. A specialist's advice is needed.

What to do about increased tics during lockdown?

# Plan the day, the more organized the day, the fewer floating periods leading to boredom and anxiety there will be. To best organize your day, you can check: https://www.debrechildpsychiatry.org/post/planning-the-day-in-lockdown-for-children-aged-3-to-11-years-old

# Incorporate short periods of schoolwork, preferably in the morning. Schoolwork can be a source of anxiety and conflict, which can itself increase tics. In order to approach this activity as calmly as possible, it is important to organize your work well: https://www.debrechildpsychiatry.org/post/how-to-get-organized-for-school-homework

# Motivate and praise your child to promote independence. The lockdown period can also be prone to certain tensions that can result in parental exasperation. The best thing to do is to try and prevent this before the atmosphere at home becomes electric: you can rely on a system of token economy that teaches the child to better manage his behaviors and to want to be more independent: https://www.debrechildpsychiatry.org/post/how-to-keep-my-child-motivated-during-the-lockdown-token-chart-or-token-economy-system

# Practice sports or physical activities at home. Some children with tics are very active and need to let off steam / exercise. In this time of lockdown, it's a bit complicated but here are some ideas on how to offer them some physical activities:

Preschool/Kindergarten: https://www.debrechildpsychiatry.org/post/psychomotor-therapy-during-home-lockdown-preschool-kindergarten

Elementary school : https://www.debrechildpsychiatry.org/post/psychomotor-therapy-during-home-lockdown-elementary-school

Middle school/high school : https://www.debrechildpsychiatry.org/post/psychomotor-therapy-during-home-lockdown-middle-school-high-school

# Be strict about sleeping hygiene. Fatigue often leads to a significant increase in tics. Parents must therefore be very vigilant so that their child has a good sleep hygiene. For specific advice on sleep hygiene: https://raisingchildren.net.au/toddlers/sleep/better-sleep-settling/sleep-better-tips

# Don’t forget to take care of yourselves as parents too: https://www.debrechildpsychiatry.org/post/taking-care-of-yourself-while-taking-care-of-others

Learn to manage the major disorders associated with tics - it's key for reducing tics

# Attention Deficit Hyperactive Disorder: Some children with tics may also be restless and/or have difficulty concentrating. This may have a greater impact in times of lockdown. To best manage these symptoms, you will find some good ideas in this fact sheet: https://www.debrechildpsychiatry.org/post/advice-to-parents-with-children-suffering-from-adhd

# Generalized anxiety disorder: Children with tics may be anxious and, in the current context, it is quite conceivable that anxiety is greater than usual. And since stress can increase tics, managing anxiety will also help decrease the tics : https://www.debrechildpsychiatry.org/post/how-to-help-your-child-anxious-about-coronavirus

# Obsessive compulsive symptoms: OCD (Obsessive Compulsive Disorder) manifests itself through the persistent and recurrent presence of obsessions and compulsions that have an impact on social, family or school life. OCD can generate stress and thus indirectly increase the Tics.

# Tantrums: Children with tics are often very impulsive and resentful, which can degenerate into tantrums and opposition. Learn how to better manage your child's opposition and impulsiveness. Some children can also be quite rigid, inflexible and question the authority of their parents, and this is more pronounced in times of lockdown : https://www.debrechildpsychiatry.org/post/how-to-deal-with-oppositional-behavior-and-rage-attacks-during-confinement

# Learning disabilities in written language: School work can be more difficult when there are associated learning difficulties in children with tics. It's easy to understand why it would be upsetting to be less successful than your classmates, for the same amount of work and effort given. This stress can also be a source of tics, so it is possible to adapt the work: https://www.debrechildpsychiatry.org/post/some-advice-to-help-your-child-with-reading-writing-disabilities-during-the-confinement-period

# Motor coordination acquisition disorders - fine motor skills and dysgraphia: these are also extremely common difficulties in children with tics. Be patient with your child who may be clumsy or have difficulty writing. His handwriting may not be beautiful, or he might be very slow. Try to be patient, use the computer if possible. You can work on your child's psychomotricity during lockdown:

Preschool/Kindergarten: https://www.debrechildpsychiatry.org/post/psychomotor-therapy-during-home-lockdown-preschool-kindergarten

Elementary school : https://www.debrechildpsychiatry.org/post/psychomotor-therapy-during-home-lockdown-elementary-school

Middle school/high school : https://www.debrechildpsychiatry.org/post/psychomotor-therapy-during-home-lockdown-middle-school-high-school

# Autism Spectrum Disorder and/or an intellectual deficit: less frequently, children with tics also have an associated social communication disorder and cognitive difficulties. It is important to manage both types of difficulties to best support your child. Be careful that the things you ask of your child are well understood and correspond to his level of adaptation and autonomy. During lockdown, management of both pathologies is often difficult. We have tried to help you as best we can with this sheet : https://www.debrechildpsychiatry.org/post/covid-19-and-autism-spectrum-disorder-what-to-do-at-home-during-confinement

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©2020 by Dr. Benjamin Landman. Child Psychiatry, Robert Debre Hospital - Paris