Since the beginning of the pandemic, doctors have been reporting an increase in adolescents, particularly girls, displaying tic-like behaviours similar to Tourette syndrome. The phenomenon has been linked to watching YouTube and TikTok videos.
Many of us would already be familiar with Tourette syndrome, which is a neurological disorder causing repetitive involuntary movements and vocal sounds.
It will generally first appear in early childhood, with facial tics usually occurring first, often eye blinking. Other movements then follow, such as head jerking, foot stamping, and twisting the torso.
The person might also repeatedly clear their throat, sniff, cough, grunt, or shout. Some of these actions, such as lip-biting and head-banging, can cause injury.
Only a small subset of people with the condition also experience involuntary swearing (known as coprolalia), says Dr Hannah Jones, paediatric neurologist and honorary senior lecturer at the University of Auckland. “Swearing in tics, although that’s often what people associate with Tourette’s, it’s actually quite rare – it only involves about 10 per cent of children with Tourette’s,” she says.
As opposed to Tourette syndrome, many of the newly diagnosed have what is called “functional tic-like behaviour”. Prior to the pandemic, referrals for these kinds of tics as the main condition made up only 1 or 2% of cases, compared to the 35% share they comprise now.
This group is bucking some of the usual trends when it comes to tic disorders, including the age of the person when the condition first appeared, speed of onset, as well as being predominantly female instead of male. “Tics typically are over- represented in boys, generally at a three-boys to one-girl ratio,” says Jones. “The common age of onset is between four and six years and they have a gradual onset in their tics. So, it was unusual to see a high number of adolescent girls suddenly presenting with an abrupt onset of tics.”
A new sensation
When a deeper analysis was conducted surrounding how this condition began or worsened, several of those with the condition mentioned they had been watching online videos of other people who had tics, says paediatrician and University of Melbourne Associate Professor Dr Daryl Efron.
“Some of the kids report that watching videos on social media, such as TikTok, either set it off at the start or they’re already having some tic and then when they watch videos the tics get worse, in almost subconscious mimicry of what they’re seeing on the videos,” says Efron.
As surprising as this aspect of the phenomenon may sound, tic behaviours are well-known for being susceptible to the power of suggestion.
“If someone has Tourette syndrome, and you ask them ‘Does your shoulder jerk?’, or you jerk your own shoulder and you show them, they may jerk their shoulder by suggesting it – that’s a known characteristic of Tourette,” says Efron.
A sensation reported by some who have a tic disorder, especially older kids and adults, is that they have a warning sign that a tic is about to come on – called a ‘premonitory urge’.
“People who have tics often describe a sensation where they know they’re about to do a tic – a bit like an itch that you need to scratch,” says Efron. “Then the action of the tic relieves the urge temporarily, and then some time afterwards, they’ll get the urge again.”
Another aspect of these conditions is that the tics are at least partially suppressible. A tic might be held at bay temporarily to let it out at a more opportune moment, but eventually the person will feel a mounting pressure to release it. It’s not comfortable to do this, but it is possible for some people.
“Kids with Tourette syndrome tend not to have many tics at school because it’s socially stigmatising,” says Efron. “They can suppress them through the day, but at the cost of a build-up of inner tension – and then after school they come out. That’s a common pattern.”
Impact on life
Depending on the severity, the effect on the person’s life can be substantial. If they’re engrossed in an activity, tics might ease, whereas in stressful situations symptoms tend to worsen. As opposed to Tourette syndrome, which tends to come on slowly and start off small, these new functional tic-like behaviours in girls have developed in a matter of days and are often large-scale movements of the arms and legs.
“They can often be self-injurious – which you do see in Tourette’s as well, but rarely – and they can be quite high amplitude thrashing movements of the arms,” says Jones. “Classic tics involve the face and close to the body such as shoulder shrugging, rapid blinking, facial grimacing, and eyebrow raising. They would probably be the most common.” Another feature of these newer cases is that they can experience a loss of function in parts of their body, such as a periodic loss of control of the legs where for portions of the day, the person’s legs will collapse under then and they will be unable to walk.
A range of mental health conditions tend to be present in those with tic conditions, but interestingly, the exact types of conditions differ between these recently diagnosed girls and the predominantly male group who have Tourette syndrome.
“The typical profile of these girls is that they have high rates of anxiety and depression, and sometimes autism spectrum disorder,” says Jones. “In contrast, the classic children with Tourette syndrome have high rates of obsessive- compulsive behaviours and attention- deficit hyperactivity disorder.”
Kids with Tourette syndrome can also have anxiety, depression, and be on the autism spectrum, but the teenagers with functional tic-like behaviour tend to experience these at higher rates. In fact, they have an anxiety disorder at four times the rate and are five times as likely to have a depressive illness.
While Tourette syndrome can persist past the teenage years, it tends to wax and wane throughout the years and abate at least to some extent as the person gets older.
“In Tourette syndrome, the tics are often worse between the ages of 10 and 12, and then they improve through later adolescence,” says Jones. “The tics might still noticeable when they’re stressed because stress is a well-recognised exacerbator of tics. So, you might still notice them occasionally in adulthood, but they’re much better and an untrained eye may not even realise the person has them,” he adds.
Girls with functional tics can also generally expect their symptoms to get better, but results vary from case to case. “The prognosis in the girls presenting with functional tic-like behaviours, they’re variable,” says Jones. “Yes, there are high rates of improvement as well, but it also has been a concerning problem and it can be difficult to treat in some.”
Treatment involves a holistic approach. Medication is not used for all cases – mainly being reserved for the more serious cases, as there can be side effects.
Psychological methods for dealing with these conditions include cognitive behaviour therapy, which is used more broadly for other illnesses. There is also a therapy specifically tailored to tic conditions called comprehensive behavioural intervention for tics (CBIT).
Also used for Tourette syndrome and endorsed by the Tourette Association of America, this therapy helps the person develop strategies to manage their tics.
A recent study indicates that this approach works – 87% of patients who found the treatment effective continued to do well six months later. The training involves making the person more aware of their tics, teaching them to do some sort of other calm, focused action instead of the tic, and making adjustments to their everyday activities in ways that help reduce their tics.
Addressing the tics also involves treating any related conditions the person has, such as anxiety, depression, and ADHD, as well as examining the stressors in their life.
“With functional tics, we try to understand what might be difficult in the child’s life. It’s different for different kids and we try to help them through whatever they’re struggling with, whether it’s their schoolwork, social world, family life, or other worries,” says Efron.
“In the pandemic, there’s probably been a whole range of worries from the micro individual level to existential angst about what’s happening – everything’s different and things have been interrupted, so there are lots of things kids have been worries about.”
Once these areas of concern are identified, practitioners can help the person find alternate ways to release or find relief from these worries.
“We then help kids to find ways to minimise the tics, and maybe trying to help them express what they’re experiencing in ways that are different to the tics,” says Efron.
How to help
If you know or encounter someone who has tics, here are some ways to show your support:
- Ignore the tics as much as possible
- Focus on what they’re saying if you’re having a conversation and be patient if the person’s tics interrupt the flow of conversation
- Don’t point out new tics – they’ll likely already have noticed
- If they appear distressed, offer them an escape such as getting some air outside, or where that’s not possible, divert their attention in a way that would seem natural to bystanders
- Keeping in mind the person’s personal preferences when it comes to being touched, a hug or a light hand on the shoulder might help lessen their anxiety