Your autistic child starts clearing his/her throat repeatedly, and while repetitive behavior may be an autism characteristic, you wonder whether the behavior may be a comorbid condition or something else…
Many parents wish they could know exactly how their kids feel; maybe then they could soothe and treat all their symptoms more effectively. When autistic children display repetitive behavior, more than just understanding why, parents are often justifiably concerned about comorbid conditions.
Certain repetitive behaviors like stereotypies (a nonfunctional, ritualistic, rhythmic movement) are associated with autism spectrum disorders. An example of this type of behavior can be seen when a child waves his/her hand rhythmically in front his/her face.
But not all repetitive movements are stereotypies. There could be more to the behavior, as there may be a connection between autism and Gilles de la Tourette syndrome. There are also other conditions, and certain medications, that may cause tics.
To children, the definitions and classification of tic conditions may be irrelevant, rather the impact of the behavior on their schooling, social, and daily life may be their primary concern. If the world could just understand that a tic is not something they can easily stop at will, and that feeling embarrassed about the behavior may in fact make it worse…
Those with a tic condition describe the lead-up or premonitory urge as akin to an itch, an uncomfortable feeling building up inside. Once the tic is performed a temporary relief is experienced.
Quite a few people, especially children, can relate to this; as transient tics are actually not that rare. Although most of us have some vague ideas about behavioral tics, our idea of tics is mostly in the realm of facial twitching and shoulder jerks. There is much more to tic disorders and children with the condition often need intervention and support.
What is a tic?
Tic disorders are neurodevelopmental conditions which often emerge in childhood and may be comorbid with attention deficit hyperactivity disorder (ADHD), autism, or obsessive compulsive disorder (OCD).
A tic could be described as a brief-lasting movement or sound interrupting normal behavior. Tics are involuntary movements or vocalizations, occurring suddenly and repetitively. Although the tic or behavior is usually repetitive, it is not rhythmic.
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) includes three types of tic disorders to help with diagnosis: Tourette syndrome, Persistent (also referred to as Chronic) motor or vocal tic disorder, and Provisional tic disorder. For classification purposes it is important to note whether your autistic child’s tic has been present for more or less than a year.
In this article, the different types of tic disorders will be discussed, not to facilitate self-diagnosis, but to help alert parents to symptoms that may need further evaluation and possible diagnosis by a professional. Your autistic child may have ADHD or other comorbidities and this may cause confusion about symptoms. This is why it is important to seek an accurate diagnosis which takes the child’s history and coexisting conditions into consideration.
Tourette syndrome (or Tourette disorder as it is also called) is a complex neurodevelopmental condition. Certain criteria must be met for a diagnosis of Tourette syndrome: for example, your child should have two or more motor tics and at least one vocal tic.
Examples of motor tics may include the following:
- Head twitching
- Blinking or eye jerks
- Sticking out the tongue
- Shrugging of the shoulder
- Facial grimacing
- Nose twitching
Examples of vocal tics may include the following:
- Throat clearing
- Yelling and screaming
Complex vocal tics could also mean a child repeats his/her own words or those of others. Repeating what others say is referred to as echolalia and it is a symptom of both autism and Tourette syndrome.
Another complex vocal tic is coprolalia which involves unintentional occurrences of inappropriate or obscene vocalizations. This can cause severe disruption in many areas of a person’s life. Less than 20% of individuals with Tourette syndrome will have an occurrence of this symptom in their lifetime (Freedman, 2009). Whether it is due to media portrayal or just a reflection of humanity, the behavioral tic of uttering swear words became the stereotype of Tourette’s. Although it seems to be the part of Tourette disorder most people want to know more about, it is still poorly understood and more research is needed.
In addition to having two or more motor tics and at least one vocal tic as illustrated by examples above, the child should start showing tics before reaching the age of 18 years. The child should have had such tics for a year, and he/she should not be on any medication that may be the cause of such behavior (tics).
Even if many of these symptoms are present, parents may still wonder whether such symptoms can be ascribed to autism or whether their child has Tourette’s in addition to being on the spectrum. A study (Darrow et al., 2017) concluded that higher rates of autism spectrum disorder (ASD) among children with Tourette syndrome may be due to the difficulty in distinguishing complex tics and OCD symptoms from autism.
The authors further concluded that a careful examination of autism specific symptoms is essential (Darrow et al., 2017). This once again speaks to the importance of accurate (professional) diagnosis.
Persistent motor or vocal tic disorder
While this condition shares some diagnostic criteria with Tourette syndrome—such as onset before the age of 18 and persistence of tics for longer than a year—multiple motor and/or vocal tics are not diagnostic requirements. A single tic or multiple motor or vocal tics (not both) would meet the diagnostic criteria for a Persistent motor or vocal tic disorder.
Persistent motor or vocal tic disorder is a less severe condition than Tourette syndrome. The next tic disorder, often described as the most common and least severe tic condition, is called a transient or provisional tic disorder.
Provisional tic disorder
To meet the DSM-5 diagnostic criteria for a Provisional tic disorder, it should occur before the child turns 18 and the diagnostic criteria of Tourette syndrome and Persistent motor or vocal tic disorder should never have been met by the child.
Many children develop a tic and it goes away without any treatment or attention. It may even cease and come back over a period of time.
Stress and anxiety exacerbates tics, or does it? A study by Conelea et al. (2014) found that tic frequency across the entire experiment did not increase during periods of higher heart rate, as one may expect. The authors concluded that the suggested results (indicating that tic exacerbations could possibly not be linked to heightened physiological arousal) mean further research is needed in this field.
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When different tic disorders are examined it becomes apparent just how difficult diagnosis must be, especially if conditions like ADHD or OCD are also present. In an autistic child, tics may also be confused with stereotypies.
Stereotypies exhibited by autistic children can be distinguished from tics in that they are rhythmic and appear to be purposeless. It also does not have the premonitory urge that precedes a tic and the subsequent relief once the tic is performed. Furthermore, stereotypies usually have an earlier onset than tics. Stereotypies often appear before the child reaches the age of three, with tics mostly appearing when the child is around six years old.
Examples of stereotypies in autism are hand flapping and body rocking. When you observe a certain repetitive behavior in your autistic child it may be difficult to establish whether it is a tic or a stereotypy; even if you ascertain that the behavior is related to a tic disorder, you will still need a professional to determine whether the child has Tourette’s syndrome or another tic disorder. For accurate diagnosis and early intervention, provide your doctor with as much detail as possible about the onset and characteristics of the repetitive behavior.
How do tics affect a child?
Most people sharing their experience of a tic talk about a specific sensation preceding a tic. A study by Reese et al. (2014) tabled the (self-reported) sensory phenomena experience before a tic of adolescents and adults with Tourette syndrome or Chronic tic disorder.
The most commonly endorsed sensations preceding a tic were described as energy that needed to escape, inner sensation of being wound up, and feelings of tenseness (Reese et al., 2014). Most of the participants in this study reported that the feelings or sensations, described above, go away after they do or complete a tic.
It’s difficult to imagine this internal build up, multiple times a day, especially for a child. A feeling of pressure, energy wound up, only to be relieved by a socially stigmatized tic. And with this negative reinforcement the behavioral cycle continues.
I have vague memories of being a young child in church suppressing a dry cough. Eyes watering and my throat on fire; the idea of letting the cough escape in that big, silent and holy space horrifying and euphoric in equal measure.
I have no idea why I considered coughing such a trespass, but the idea of having an urge that can only be relieved through a behavior that may be frowned upon must be terrifying for a young child. Especially in a school setting where children often pick on any behavior deemed different.
Studies found that children with Tourette syndrome experienced more bullying, victimization, and perpetration than children without the condition (Charania et al., 2021). Other studies also found that children with Tourette syndrome were more likely to experience school challenges like having to repeat a grade (Claussen et al., 2018).
Of course Tourette syndrome is the most severe of all tic conditions; many childhood tics are temporary, many disappear without intervention after less than three months. Further encouraging news is that there is therapeutic promise in behavioral interventions for chronic tic conditions.
A study (Kim et al., 2019) examined tic suppression in children with recent onset tics. The study was undertaken to determine whether the capacity to suppress a tic predicted severity of tics in future.
The study (Kim et al., 2019) found that children who had tics for only a few months could suppress tics. Suppression was especially successful when children received an immediate reward. The study may be valuable in terms of inhibitory control over tics in the early period of onset.
Studies such as the above stress the importance of early intervention in conditions like Tourette syndrome which may be comorbid in autistic children. A further study (Bennett et al., 2020) detailed success when the Comprehensive Behavioral Intervention for Tic Disorders (CBIT) was adapted for use in young children.
Treatment and intervention may prevent the chronic course of tic symptoms, this is why parents should never downplay the role of interfering and repetitive behaviors as just another symptom of autism.
Bennett, S. M., Capriotti, M., Bauer, C., Chang, S., Keller, A. E., Walkup, J., Woods, D., & Piacentini, J. (2020). Development and Open Trial of a Psychosocial Intervention for Young Children With Chronic Tics: The CBIT-JR Study. Behavior therapy, 51(4), 659–669. https://doi.org/10.1016/j.beth.2019.10.004
Charania, S. N., Danielson, M. L., Claussen, A. H., Lebrun-Harris, L. A., Kaminski, J. W., & Bitsko, R. H. (2021). Bullying Victimization and Perpetration Among US Children with and Without Tourette Syndrome. Journal of developmental and behavioral pediatrics : JDBP, 10.1097/DBP.0000000000000975. Advance online publication. https://doi.org/10.1097/DBP.0000000000000975
Claussen, A. H., Bitsko, R. H., Holbrook, J. R., Bloomfield, J., & Giordano, K. (2018). Impact of Tourette Syndrome on School Measures in a Nationally Representative Sample. Journal of developmental and behavioral pediatrics : JDBP, 39(4), 335–342. https://doi.org/10.1097/DBP.0000000000000550
Conelea, C. A., Ramanujam, K., Walther, M. R., Freeman, J. B., & Garcia, A. M. (2014). Is There a Relationship Between Tic Frequency and Physiological Arousal? Examination in a Sample of Children With Co-Occurring Tic and Anxiety Disorders. Behavior modification, 38(2), 217–234. https://doi.org/10.1177/0145445514528239
Darrow, S. M., Grados, M., Sandor, P., Hirschtritt, M. E., Illmann, C., Osiecki, L., Dion, Y., King, R., Pauls, D., Budman, C. L., Cath, D. C., Greenberg, E., Lyon, G. J., McMahon, W. M., Lee, P. C., Delucchi, K. L., Scharf, J. M., & Mathews, C. A. (2017). Autism Spectrum Symptoms in a Tourette’s Disorder Sample. Journal of the American Academy of Child and Adolescent Psychiatry, 56(7), 610–617.e1. https://doi.org/10.1016/j.jaac.2017.05.002
Freeman, R. D., Zinner, S. H., Müller-Vahl, K. R., Fast, D. K., Burd, L. J., Kano, Y., Rothenberger, A., Roessner, V., Kerbeshian, J., Stern, J. S., Jankovic, J., Loughin, T., Janik, P., Shady, G., Robertson, M. M., Lang, A. E., Budman, C., Magor, A., Bruun, R., & Berlin, C. M., Jr (2009). Coprophenomena in Tourette syndrome. Developmental medicine and child neurology, 51(3), 218–227. https://doi.org/10.1111/j.1469-8749.2008.03135.x
Kim, S., Greene, D. J., Robichaux-Viehoever, A., Bihun, E. C., Koller, J. M., Acevedo, H., Schlaggar, B. L., & Black, K. J. (2019). Tic Suppression in Children With Recent-Onset Tics Predicts 1-Year Tic Outcome. Journal of child neurology, 34(12), 757–764. https://doi.org/10.1177/0883073819855531
Reese, H. E., Scahill, L., Peterson, A. L., Crowe, K., Woods, D. W., Piacentini, J., Walkup, J. T., & Wilhelm, S. (2014). The premonitory urge to tic: measurement, characteristics, and correlates in older adolescents and adults. Behavior therapy, 45(2), 177–186. https://doi.org/10.1016/j.beth.2013.09.002