Tic Disorders

A tic is a sudden, rapid, recurrent, non-rhythmic movement or vocalization. 

Tics can be simple (rapid, meaningless) or complex (more purposeful, elaborate), and transient or chronic.

Tics are frequently preceded by urges or sensations which may permit the child to suppress the tic temporarily.

Tics may be socially and emotionally impairing if the response of those around the child includes punishment, ridicule, or marginalization.  

Tics are common, occurring in 5% or more children.

Mean age of onset is 6-7 years, with 65% improved by age 18.

Tic Disorders

Motor or vocal tics for > 1 year = Persistent Motor or Vocal Tic Disorder 

Chronic motor + vocal tics > 1 year = Tourette’s Disorder


90% will have a comorbid psychiatric diagnosis; over half will have ADHD, nearly half will have OCD. 

Patients with Tourette’s, ADHD and OCD have higher rates of Autism Spectrum Disorder than have control patients. 

Up to 44% of girls with Tourette’s have an anxiety disorder.


Begin with psychoeducation.  Share information on the Tourette’s Association of America (http://tourette.org). 

Key messages for patients and families:

  • Tics are not deliberate. 
  • They are not the child’s fault. 
  • They will wax and wane over time. 
  • They will get worse when the child is stressed or excited. 
  • They will diminish in intensity and frequency as the child gets older.  

In thinking about treatment, consider the preferences of the child and family, and available resources.  Watchful waiting combined with education about tics is often a viable option. 


Comprehensive behavior therapy for tics (CBIT) is first-line treatment.  CBIT includes psychoeducation, functional behavioral analysis and habit-reversal training.  CBIT is as effective as antipsychotic medication in reducing tic frequency and severity.  

Watch a video demonstration of CBIT with an adolescent with a tic disorder.


Alpha agonists are considered first-line treatment for tic disorders because they are relatively safe and well-tolerated although evidence for efficacy is limited.

  • Guanfacine, immediate- and extended-release
  • Clonidine, immediate- and extended-release

See alpha agonist dosing and side effect information.

Antipsychotics are more effective than are the alpha-agonists in controlling tics, but their adverse effect profile makes them second-line treatment and only appropriate for more severe cases. 

Treat comorbidities: 

There has been concern in the past about stimulant treatment of ADHD causing or worsening tics.  A recent meta-analysis of 22 studies involving 2,385 children with ADHD indicates that this not the case. New onset tics or worsening of tic symptoms reported in the psychostimulant (event rate = 5.7%, 95% CI = 3.7%-8.6%) and placebo groups (event rate = 6.5%, 95% CI = 4.4%-9.5%) occurred at the same rate (Cohen et al, JAACAP 2015).

Acute-Onset Complex Tic-like Behaviors in Adolescence

During the period of the COVID-19 pandemic, clinicians around the world observed an increase in adolescents presenting with tic-like symptoms characterized by acute onset, atypical course and often marked impairment.   This atypical presentation may be distinguished from the typical clinical presentation of Tourette’s Syndrome as follows:

Tourette's Disorder Acute-onset complex tic-like behaviors
Childhood onset (age 4-8 years) Adolescent onset
male to female ratio 3-4:1 predominantly female
Begins with simple movements or vocalizations that may increase in complexity over time Abrupt onset of complex motor movements (complex limb movements, hitting, forceful head and neck movements) and vocalizations (coprolalia, echolalia, speaking in an accent, complex phrases)
Most experience premonitory urge and ability to temorarily suppress tics. Rarely report premonitory urge; ability to temporarily suppress tics is variable
ADHD and OCD are common comorbidities. Anxiety and depression are common comorbities.

Acute-onset complex tic-like behaviors in many patients may represent a functional neurological disorder in some cases influenced by social media exposure, including TikTok Tourette’s Syndrome influencers.  Treatment for tic-like functional neurological disorder may begin with motivational interviewing and include supportive or Cognitive Behavioral Therapy (CBT). 


Frankel, J., Abdullayeva, N., Mavrides, N., & Coffey, B.  “Tic Disorders” in Dulcan’s Textbook of Child and Adolescent Psychiatry, Third Edition.  American Psychiatric Publishing: Washington, DC. 2022.

McGuire, J. F., Bennett, S. M., Conelea, C. A., Himle, M. B., Anderson, S., Ricketts, E. J., Capriotti, M. R., Lewin, A. B., McNulty, D. C., Thompson, L. G., Espil, F. M., Nadeau, S. E., McConnell, M., Woods, D. W., Walkup, J. T., & Piacentini, J. (2021). Distinguishing and Managing Acute-Onset Complex Tic-like Behaviors in Adolescence. Journal of the American Academy of Child & Adolescent Psychiatry, 60(12), 1445–1447. https://doi.org/10.1016/j.jaac.2021.07.823