Ep 221: Navigating Childhood Tics and Tourette Syndrome: Expert Insights with Dr. Greenberg

Navigating Childhood Tics and Tourette Syndrome: Expert Insights with Dr. Greenberg

In this  episode, we sit down with Dr. Greenberg, director of the pediatric psychiatry OCD and Tic disorders program in Boston, to discuss the complexities of childhood tics and Tourette Syndrome. Dr. Greenberg shares her extensive expertise and personal experiences to help parents understand what tics are, how they manifest, and their natural progression. She provides insights on effective treatments such as CBIT therapy and when medication might be necessary. Additionally, Dr. Greenberg emphasizes the importance of differentiating between normal tics and those that may indicate other co-occurring conditions like ADHD and OCD. This episode is a must-watch for parents seeking reassurance and practical advice on managing their child's tics.

Erica Greenberg, M.D. is an assistant Professor in Psychiatry at Harvard Medical School and a child/adolescent psychiatrist at Massachusetts General Hospital (MGH) where she is the Director of the Pediatric Psychiatry OCD and Tic Disorders Program. Dr. Greenberg is also a co-Director of the MGH Tourette Association of America (TAA) Center of Excellence and the co-president of the Medical Advisory Board of the TAA. Her interests include Tourette syndrome (TS), OCD, “Tourettic OCD,” ADHD, body-focused repetitive behavior disorders, and other Tourette syndrome spectrum conditions. She has authored several peer-reviewed manuscripts on TS, OCD, and related disorders, and has presented on these conditions nationally and internationally. Dr. Greenberg graduated from Weill Cornell Medical College with Alpha Omega Alpha honors, and completed her general psychiatry residency at Harvard Longwood and her child/adolescent fellowship training at MGH.

Contact Dr Greenberg: MassGeneral Brigham; Massachusetts General Hospital for Children
Pediatric Psychiatry OCD and Tic Disorders Program
Email: MGHPediOCDTics@partners.org
617-643-2780

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Transcript

Unknown: 0:00

Hi everybody, and welcome back to your child is normal. I'm your host. Dr Jessica Hochman, so today we're talking about something that comes up all the time in my office as a pediatrician, childhood ticks. This is a topic that I've been wanting to cover for a while, because tics are incredibly common. Studies suggest that up to one in four children will have a tic at some point, and while they're usually not harmful, they understandably worry many parents, so I'm very excited to introduce to you today's guest. I'm joined by Dr Erica Greenberg, who is incredibly knowledgeable about tics. She works with children and families dealing with this every day, and she's also the director of pediatric psychiatry, OCD and tic disorders program at Mass General Hospital in Boston, and I honestly feel lucky to have had the opportunity to interview her. In this episode, we talk about what tics can look like, what Tourette's Syndrome is, what the usual course of tics is over time, and when treatment like an evidence based strategy called CBIT andor use of medication may be useful options. And if you found this episode helpful for you, I'd be so grateful if you could take a moment and leave a five star review or share this podcast with another parent. And by sharing this podcast, you're helping me accomplish my personal mission of sharing non click bait, quality content so you can spend less time worrying and more time enjoying your children. Now on to my interview with Dr Erica Greenberg. Dr Greenberg, I'm really looking forward to having this conversation. There are so many patients that come to me and talk about their child's tics, and they want to know what to do, how to proceed. Should they do anything? And so I'm happy to have you here to help give patients good information, to help guide them appropriately. Yeah, absolutely happy to be here and happy to be speaking about this topic, which is near and dear to my heart in everyday practice. So to start, will you tell us a bit about yourself? Where do you work, and what kind of work do you do? Yeah, so I am, I'm in Boston. I'm the director of the pediatric psychiatry OCD and tick disorders program, where we have a robust, small, robust clinical program with about four staff that we see children anywhere between ages like three, four, up to usually 18, maybe a little higher, who present with either tics and or obsessive compulsive disorder, and those two we see pretty commonly together and or any of the common conditions that we often see in kids who have tics or OCD. And I'm curious what drew you to work with kids with tics and OCD? Was there anything in particular that happened in your life, or is it something that just has always interested you? Yeah, so I was always interested in the interface between Psychiatry and Neurology, just in general, that area had always been highly interesting to me, and I had always enjoyed working with kids and Kid populations, and then, more specifically, towards Tourette, my younger brother, was diagnosed with it when I was in high school and then early parts of college, and so I saw his experiences, learned from him. I had my own experiences as a sibling. I saw my parents have their experiences in terms of a new diagnosis that at least back then, certainly carried a lot of stigma and how they navigated it, and he's grown over the years into a great young man, but it kind of gave me a foray into the fields. And so I did my medical training at Cornell in New York City, and then I did my residency and psychiatry training in Harvard, Longwood in Boston, and then my child fellowship in Mass General McLean in Boston. And then shortly after graduating, I've been doing this full time. That's fantastic. So it sounds like you're really well trained, and also, I'm sure that your experience with your brother has made you an extra compassionate doctor. So how lucky for your patients? Well, I try, but yes, everyone's experience is different and unique, which I think is always super important, never to assume that I will understand something just because I've seen it in my family or in other patients, but I think it helps give a little bit of an extra lens of that proxy lived experience that is hopefully helpful Absolutely. And I have to tell you, I feel like a podcast on ticks and Tourette's is really long overdue, because it's something that comes up so frequently in my office, and causes so much stress for families. So I think getting an overview and getting a deeper understanding about what they are, what the natural course of ticks to be expected will be, and what parents can actually do about it, I think will be really helpful. So very grateful for your time. No absolutely, and I happy to be sharing about it. And I think to your point, once you know what ticks are, you'll see them everywhere, because they're actually quite common, so up to 25% and some studies say a lot more of people will have a tick at some point in their life. And so what are ticks? They're sudden, brief, repent. Additive or recurrent movements and or sounds. And we use the word stereotyped meaning that they will look a certain way each time. And so we often divide tics into either motor or vocal meaning it either is a movement or a sound. And we divide them into simple meaning it's a sniff or eye blink, sort of one muscle group, a short sound, and then more complex tics, which often look more deliberate or coordinated groups of muscles and or sounds, but are still tics in the sense that they are this recurrent, stereotyped, brief and sudden. What we know about ticks is that they tend to typically start around ages like five to seven, could be earlier, could be later. Typically start in the head, off, in the face, head, neck, and then they might travel down and outwards. They typically start motor movement, and they typically start simple, and then might progress to more complex, and they often will jump from location to location. You might see eye blinking for a few weeks, then you might see shoulders shrugging, then you might hear sniffing. They're highly suggestible, which is something I think is really important for parents and teachers to know. So a lot of times when kids come to my office and we'll talk about ticks, and they'll get frustrated because they'll say, I wasn't ticking, but now that we're talking about it, of course, I'm ticking, and that's true. They're suggestible, similar to a yawn. You see someone yawn, you want to yawn. It's similar way in that the more you talk about them, the more you see them, they tend to increase for periods of time, decrease for periods of time. We don't totally understand why. There's likely a number of different factors that contribute. But another thing that I think is really important for parents to know is just because you see increased tics doesn't mean that there is something definitely going wrong at school, at home, with one's mood, with the anxiety. We know that being more anxious or really having any emotion can trigger or worsen ticks, but the presence of them alone doesn't mean that you're missing something, and if they are getting worse on their own, again, it doesn't mean that there is necessary. Might be something going on, but it doesn't have to be. And then the last part that I probably should have led with is in terms of what are ticks we like to use the word unvoluntary. So they're not voluntary. They're not like a deliberate choice, controlled choice of action. They're not involuntary. They're not happening against one's will. It's not like the person isn't aware, or their arm flails, or these are happening like to them. It's in the middle. It's unvoluntary, non voluntary, more like an irresistible urge, like a terrible itch, or that feeling before a sneeze or a yawn. So the person is often aware, not always, but often aware they're doing it. It's just so discomforting and hard to stop that even though there might be negative issues associated with doing it, the difficulty of not doing it is so hard. I do find when I talk to parents, sometimes they have a hard time telling if their kids are aware that they're ticking Yeah. So for example, they'll be watching TV and moving their neck and shrugging their shoulders, and the parent will ask them, Do you know that you're doing this? And the kid sometimes says, yes. But I think a lot of times, really, they don't know that they're doing it. They're not aware. Yeah, there are, on the contrary, kids that are definitely aware that they're doing it, and very self conscious that they're doing it exactly, exactly. And it, I would say it's more common than not that kids are unaware when it's happening. It's more that, if you bring awareness to it, they should hypothetically be able to briefly suppress it, even if it's for a moment, as opposed to other movement disorders, that no matter how hard you try, you can't stop it. If you bring awareness to it, they can acknowledge that movement is happening exactly, exactly, but it's so so common that kids, especially, yeah, watching TV, really, doing anything, will be ticking and not realizing and that's fine, and in those cases, no need to bring awareness. But what you're also talking about is what we call a premonitory urge, and that's like a fancy way of describing a sensory, uncomfortable itch. I've heard all these different words, feeling that the person experiences before the tick again, like that feeling before a sneeze or a yawn, that the tick then relieves, and often on the whole around age 10 is when you start to see kids report. Supporting having these premonitory urges, and then knowing that this is then driving the tick in any particular moment younger than that. I have a lot of kids who will describe that. I have a bunch that don't. But what's helpful about that premonitory urge is that if you start to talk about behavioral therapy, you'll use that feeling as a way to work through the different ways to think about trying, at least to suppress tics. That makes a lot of sense. That makes a lot of sense. So just to think about the science behind tics, do we have any idea as to why tics actually happen? Yeah, that's such a great question. Yes, and no, we know that there's a brain circuit called the cortical, striatal, thalamocortical cstc circuit that basically connects your frontal cortex, the part of your brain that helps you make decisions and planning organization, to the basal ganglia, which is the part of the brain more in control of movement, and then back up to the cortex. And so we know that that circuitry tends to be involved or will look, not necessarily atypical, but different than in those that don't have ticks on the whole so we believe that circuit is what's implicated. And there's lots of theories around why you might see different ticks at different ages, in terms of growth and development and just brain changes over time. And we also know that there's a really strong genetic component. And so I always forget the exact stat, but I think it's about 70 to 80% of ticks within tick disorders are thought to be linked to some genetic predisposition. What's interesting is that it doesn't have to be that the parents have ticks. It's also linked genetically to OCD and a little bit to ADHD, but that's a little more complex. So if you have a parent that has OCD genetically, you'll be more likely to have a child that might have ticks. And you have ticks, same thing, and vice versa, and it's about a three and a half to one ratio in kids, of boys to girls, one of the questions that were often asked, Is this going to be forever? Is it going to go away? What's going to happen? And the good news about ticks is, chances are, more than not that they are going to get better as kids get older. So we often see it start around age like five, five to seven, then it continues off on up till around age 10, and then, unfortunately, mainly because it coincides with junior high years and puberty, which is why we think that there's multiple factors worsening, often between the ages of around 10 to 1310, to 14, and then on the whole, as one enters late adolescence, or their later teens, early 20s, you tend to see improvement on the whole, with about a third of people with ticks essentially disappearing, not totally, but close enough to none, about a third significantly improving, and about a third continuing with only about 20% continuing to be more significantly problematic. And for that 20% it's really hard, and we have treatments and we have strategies and suggestions, but on the whole, that's about four out of five as they get older, doing better. There's some new data saying that for girls, it that, course, it's still on the whole better as one gets older, but it's less clear that in girls, females, that you're going to see that same dramatic reducing that you tend to see in boys, the rates of those with tic disorders in later teens adults is more one to one, male to female, and females might have a little bit more complex tics, vocal tics. So I think it's something that we should keep an eye on. But it doesn't change the fact that, on the whole tics tend to get better as one gets older and gets out of those puberty years. I think that's a very important and helpful reminder that if we do nothing, regardless, the trajectory is positive, that they're likely to improve over time. One thing that you just said that surprised me, that I wasn't entirely aware of, is that during puberty, tics can get worse. I think what I've noticed in my office is that I'll see a lot of motor tics in particular, you know that age seven to 10, and then for a lot of kids that I meet, it seems to improve. And I think to myself, thank goodness, because Middle School, those are the years where the kids get teased, they're more self conscious. So that's unfortunate that that's not the case, yeah, and I'd be at some point, I just need to, like, speak with a pediatrician, and I've talked to a few parents who I work with that are pediatricians in terms of, like, the correlation with Tanner stages, because it seems once you're more four or five, things are now starting to get better, but it's more later into puberty, exactly, but it's earlier. It's right before the big growth spurts. And again, I learned a word V. Recently at a conference that I like anec data, that's more like anec anec data, but I think you also do see a lot of kids, like nine to 10, I feel is the most commonest age to see ticks. But then in terms of that worsening, I think for those that are going to worsen, you'll then see it in the those couple years after. But just because they worsen doesn't mean they're not going to get significantly better, and that's where it is helpful. I can think of my brother who had ticks from a young age that no one knew were ticks because we didn't know what it was that then they sort of exploded, for lack of a better word. You know, age 1011, continued to be severely problematic. And I can get into what that means, because having ticks itself is not problematic. It's problematic if it causes distress, pain interference, psychological or physical. So he was experiencing those and then by age 1516, they began to get significantly better, and he still has some that occasionally bother him more than others, but I don't know that if he met anyone now, for the last 20 years, anyone would assume that he had a tic disorder. That's great, right? And that's like the typical course, and not for everyone, but I want to make sure parents know, yes, I'm sure it's better if you don't have tics, or if you have super mild tics, in terms of course, but just even if you do have pretty severe tics, that doesn't mean that things can't get a lot better after those puberty years. It's great to hear okay, so we were just talking about the most common motor tics and the most common vocal tics. So you'd mentioned eye blinking, you'd mentioned grunting, you'd mentioned shoulder shrugging. Are there any other common tics and common vocal tics that you see in your practice? Oh, yeah, all the time and again, once for people listening to the podcast, I'm sure if you walk down the street now you're gonna see them like really, all the time, but a lot of eyes, a lot of eye movements. So whether it's rapid blinking, eye rolling, which is really important because a lot of kids will get in trouble because teachers or parents think they're rolling their eyes, but it's a tick sniffing is a super, super common one. And what's also tricky is that one of the theories in terms of how ticks form, is just a propensity to over learn, and so a lot of times, someone will get a cold, have sniffles, and then long after the cold is gone, will continue to sniff, which was unfortunately, really problematic in the pandemic, because many kids either a Developed sometimes ticks develop in a way that it's like, what is something that I don't want to happen? And then the more you think about it, the more where you do are, the more you do it. So there was that, but then also just in terms of lingering symptoms. So in addition to sniffing, coughing is a super, super, super common tic. So a lot of times kids are brought to pediatricians, to eye doctors, to allergists to pulmonologists, for either chronic cough, chronic sniffles, chronic like blinking and in reality, they're ticks. The underlying thing that might have started it is gone. It's almost like it's become, it's become a habit, exactly, I think. In fact, pulmonologists call it habit cough, but it's a tick, but it's common vocally. And I guess the sniffing and the coughing, those are counted as vocal ticks, and by that, speaking of anecdata, I completely agree with you that I seem to experience a flare in childhood ticks during the pandemic of coughing, of sniffing, of many simple motor tics, yeah. And that gets into so many questions. There is links between inflammatory processes and ticks. And in like huge studies of millions of kids in Denmark, Sweden, in those kids that have more inflammatory conditions, more history of infection, strep or non strep, more likely to have ticks. And so there's this, we don't know, chicken or the egg, correlational, certainly correlational versus causational. And we think that the same genes that predispose you to having ticks are shared with the genes that predispose you to having inflammatory conditions. And so there's this automatic already crossover. And so it's people always question, oh, is those who had covid gonna have more tics? Maybe, maybe not. I don't think it's any different from any other illnesses, in respect that we've always coexisted with these and certain people are more susceptible than others, but I do wonder about that fear component of if I cough, the more anxiety and the more feeling of I really shouldn't do this. I don't want to do this now I did. It was probably also heightened in the pandemic. Very interesting. And then as far as you were about, to mention simple vocal tics. So common ones there are humming actually, which can be tricky. And to me, is a little different from a typical tick in the sense that it's not grief recurrent, it's more ongoing. But humming in general, that's again I'll probably Veer, veer off. But you want, when you have a kid that has ticks, you want to be watching for OCD and ADHD. Those are super common in kids with tic disorders, and so with humming, that might also be like an inattentive kind of, not non awareness. So, but humming is a common vocal and squeaking, and I would say those and sounds are just the more common vocal tics. Kids get really good at masking tics on their own. And so I'll have a bunch of kids that might have a laugh tick, and then we'll start like, laughing or say something so that they're trying to make it look like, Oh, that was intentional. Exactly, exactly, which, if it works, fantastic, if it doesn't, that's when we start. We can think about treatment. But again, that that is going to go back to that main point of just because you have ticks doesn't mean it's a problem. It's a problem. And this is something I say to the parents all the time, I don't mind. You shouldn't mind if the kid has ticks. I mind if it bothers them. I say this all the time to families, and I think it's so helpful to hear you say it, because a lot of parents are concerned, will those movements hurt them physically? You know, for example, if a child moves their head and their neck a lot and really flares their head and neck, sometimes the movements can look forceful, and parents worry, are they going to be hurting themselves? And so what you're saying is it's unlikely. Correct, exactly. It's not impossible. And I think there's a very, very rare, particularly like with neck jerking backwards, that we try to keep an eye on. But I would say that's the exception, rather than the rule. Parents are always super worried that they're hurting themselves. And one thing that is probably under reported and under asked about is pain in Tourette, but again, that's the subjective experience of the person. If someone is jerking their neck a lot, it can get sore. It does get sore. And then we speak about Zeds or heating compression, but it's it is extremely rare that I'm worried that they're actually going to hurt themselves because of the tics themselves, not impossible, but now we're talking like those are kids that are experiencing ticks to that degree, are, by that point, almost certainly seeing neurologists psychiatrists like this. It's that you're asking your early line pediatrician. I'm not worried what I should say in terms of the vocal tics when people hear Tourette, they think Corporal earlier or swearing. And do not have to have that to have Tourette all. Tourette syndrome is two motor tics and one vocal tic for at least a year, off and on, coming and going. It is very easy actually to meet the criteria for Tourette Syndrome, it used to be that you had to have impairment. They got rid of that criteria many years ago. And so I think Tourette, it's cited around point five, 1% other chronic disorders. Another one to 2% is probably higher if you eliminate that distress criteria, because again, all you need two motor one, vocal. About 15 to 20% of people with Tourette will have Corporal Alia, and for them, it is hard, and we speak about treatments, but, but I really want to separate the difference between a single symptom that some people have and the vast majority of people who don't have it. And just because you have Tourette does not mean you're going to develop Corporal Alia. And two quick questions there for people that aren't aware, what is corporalalia? Yeah, so corporalia is, I won't try to translate Latin, but basically, obscene words, swearing, racial slurs. That's what we mean by praxia. Is obscene movements. So that might be the physical the motor tic component, so raising one's middle finger, doing like thrusting motions. And so those are often linked, if it's not uncommon, if you have one to have the other, but that's those are some of the more, probably the most severe ticks interact. Yes, that must be so stressful for the parents and for the child. And then next, just to quickly paint a picture for somebody, what it might look like if somebody has Tourette's, when you say two motor tics and one vocal tic, so I'm picturing a child, eye blinking, grunting and then humming. Would that be an example of a someone with Tourette's? Yeah, I guess you if you count them separately. That would be two vocal, one motor, but, yeah, a Tourette diagnosis could be as simple as blinking, a few shoulder shrugs and sniffing, makes sense. Okay, so we've got two motors, one vocal, two motors, one vocal. It's, again, like to make a sound, you need to move muscles, and so there's a push to separate this the. Distinction between motor and vocal, because it's a false distinction, but at least for now, that's the way. And again, you could have them when you're five, for a couple months, and then nothing, and then when you turn six, have a few more like it counts. It's that's why I really think it's the rate of people who meet criteria for, quote, Tourette syndrome is probably a lot higher than we think. I definitely would agree with that, and I agree with what you said before, that, once you start noticing them, you notice them all the time. Yeah, I probably think is a good thing that most people don't notice them so much, or like the fact that one of the big takeaways is kids with tics are normal kids. They're like, they're they're actually, is some like links, perhaps about like, brighter, more creative, quicker, like it has positive attributes, witty that have been associated. I won't try to explain why or how, other than it's shown up, but like a ton of successful people with ticks, you just don't know that those are ticks until you know what to look for. Yes, which is interesting, yes, I'm thinking particularly for spouses out there who think maybe their husband or wife has an annoying habit. It's not their fault. A lot of that vocal Grunt is just a tick Exactly, yes, doing it to annoy you intentionally, exactly and bringing attention to it, unless they're in treatment, and I can talk a little bit about treatment, c bit comprehensive behavioral intervention for ticks. But unless the person is explicitly working on the tics with the plan, you telling them to stop, it is not going to help. A if they're an adult, they prompt they might not know they're doing it, but if they do, does telling anyone to stop, like, that's yes, that be if only we were that easy, it's likely to make it more stressful, which is going to increase tics. And parents will also think tics have to are, like, anxiety driven. They're excitement driven too. They're really anything that keeps you off of your sort of like, copacetic status quo can exacerbate ticks. So the story is always like going to Disney World for December break and happy place, lots of excitement, lots of overstimulation, ticks might go off the chart and then come home, and then they might go back to typical level. I'm glad you bring this up, because I do meet a lot of parents who want to help lessen their child's tics, which I understand, and they worry that stress plays a component in worsening their tics, and so they'll do whatever they can to make their child's home life, social life, personal life, as least stressful as possible. But then I think it's not real world. If you think about it in the lens that the tics aren't hurting the child. It's not real life. If we really are trying to do everything to decrease their external stimuli at the expense of lessening their tics, they're not going to be living their life, they're not going to be engaging socially, they're not going to be trying their hardest in school. And I think overall, it ends up being not as helpful for the child as we would think. Yeah, I think you hit the nail on the head, and that's like with the CBI T therapists I work with, that's a message that they really want to drive home. That's negative reinforcement. So if, if you're having a lot of ticks, and now you're having a lot of ticks, so you don't have to do your homework, well, that's not gonna encourage you to not tick like you really have to watch out for taking stressors away, inadvertently exacerbating the system. It's really the goal is to do what you do normally, what you enjoy doing, and keeping expectations just as you would keep them if they didn't have ticks. There's always caveats, there's always exceptions. There's always periods of time where, you know, maybe for these few days or weeks while you're changing something, you it might be a little different. But on the whole, the goal is not to just reduce stress in the environment. It's not real, and you're just kind of setting up for further problems down the road in terms of anxiety and just more negative reinforcement patterns. It's all so interesting because I do think a parent's natural inclination when you see your child ticking is to tell them to stop. You want to help your child, but it sounds like parents intervening, for the most part, isn't helpful. Exactly. The more you can call me ignorance or ignoring. If you can't, like ignore, the less attention, the better. Positive attention, negative attention both continue the cycle of increased tics. So I have parents that I've met who swear that they've told their child they have to stop, and that's worked. So I'm just curious, from your perspective, is there ever a situation where a parent should bring up a tick to the child and tell them to stop, or is it general advice that it's best to ignore? Best to ignore? I'm sure if I racked my brain, I could think of a situation. It's tough to think of a situation that the child isn't already aware that a parent telling them to stop is going to be helpful. Tough for me to believe that a parent telling a. Kid to stop. Actually cause the ticks to stop. They again, you can suppress them for periods of time, and that's what the therapy helps you work on. But each tick is unique, and again, if it were that easy, people would do it. So what I could also imagine is the tick jumped. It came and went. Just because you treat one tick doesn't mean it's going to pop up somewhere else. They all have their own kind of rhythm. So that would be more my guess that after a few weeks of saying stop, the Tick was probably going to go away on its own. Yeah, I have to tell you my mother in law, who listens to this podcast yesterday, I was telling her about the topic of today, and she said, Oh, when my son had a tick, I just told him to stop, and it worked. Yeah, I always say never, say never, but no, like that would not work. Vast majority, slash, all the time. Okay, so in terms of kids that are more at risk for developing ticks, you mentioned genetic predisposition, males are more likely than females, any other group we should think about that is more likely to develop ticks? Ooh, you know what? It's a great question that I probably have to think more about. We know that they're more common in certain ethnic or racial populations, so I think French Canadian, Ashkenazi Jews, they're still prevalent across the world. It's not it used to be thought like not in Sub Saharan Africa. There's a few papers that say that's not true. They're prepped. They're represented all ethnicities, races, but there's certain ones that are more, perhaps more likely to be expressed. But other than that, I mean again, the other like really big takeaways, less about which cohorts, but more the real reason you want to pay attention as a pediatrician, if you see a kid with ticks, is because of the comorbidities. And the comorbidities are actually often what's more problematic than the TIC themselves in kids with tic disorders. And again, a lot of these comorbidities are all associated with this, that cortical, striatal, phalama, cortical loop that I mentioned earlier, and so ADHD and OCD are the two most common, but you want to watch for anxiety. ASD, not necessarily full ASD, but some symptoms which that's a whole topic onto itself, in terms of over diagnosis, particularly in those with Tourette, but it's it is more common certain learning disabilities, impulsivity, which goes with the ADHD, disinhibition, body focus, repetitive behaviors, hair pulling, skin picking, sensory hypersensitivity. I'm sure there's a few I'm leaving out. And again, it doesn't mean that if you have tips, you will have all of those. It just means those are the things you should be keeping an eye on. Ticks have their natural course to our knowledge, regardless of whether we intervene or not. Those other conditions, if you don't, can continue to get worse and develop into further conditions. Yeah, I think the point that you're bringing up is a great one big picture, the tics themselves are not harmful, but being aware of the tics is important because it may also draw your attention and awareness to other conditions that are related to having tics, and that can be very helpful, exactly, and that's where you should and can intervene. What I will say about tics is that in a lot of surveys that the Tourette Association of America, I think I don't know if I have to disclose I'm on the Medical Advisory Board. I don't get paid, but they have great resources for kids, for families, for schools, great informational packets. But they did a study on the impact of ticks on kids, and the biggest problem, if ticks were a problem, was the impact on school. And so we really recommend if, again, if the child has simple tics and they are not bothered, you don't need to bring it up to the school. You shouldn't bring it up to the school if ticks are starting to get in the way or those co occurring conditions. It's really important to work in the school. And a few times I'll be at lectures where one of my colleagues is basically giving a talk and saying, okay, when you have to write the Pledge of Allegiance, and every time you know you have to count to four, and whenever you count to four, you have to blink and now try to write the Pledge of Allegiance, it's distracting. It can be really hard, whether that's OCD or ticks. The point is that there's a lot of things that get in the way of being able to pay attention, in addition to the fact that there might be ADHD for those with ticks, and you don't want kids to be double punished, which I think of as if the tics are bothering them and now they're being punished for the tics, that's even worse. So working with the school so that the school doesn't point them out, they don't sit them at the front of the class, perhaps the back of the class, or wherever the kid feels most comfortable. They can take movement breaks if they need to, if they have vocal tics, letting them chew gum. Have an extra water bottle to help, maybe mitigate some of the tics, but it's really like bullying and problems in school are some of the biggest problems that we see, and we just need better intervention and better understanding. Ending. So I'd love to ask you about treatment, because this is a big question that parents have. So I agree that for most kids it's important to ignore the tics and watch the natural trajectory. But when is the time when we should be recommending interventions? You had mentioned c bit, CBI, T therapy, and I know there are also medications that may come into the picture. So what is your recommendation from that aspect? Yeah, so right now we're thinking like, what do you do if it's an issue? So again, like, how we're defining an issue that needs help is if it's bothering the child, psychologically, physically, socially, and that's when we're thinking treatment, CBIT, comprehensive behavioral intervention for tics, which I won't go into the details, but it's essentially a behavioral therapy that helps kids recognize the feelings that they have before they are having the tics, and then develop either competing responses or other strategies that help to then reduce the ticks. And it's hard, it's work, but that's always our first line treatment. If someone can find a provider that does it, which is tricky, again, TAA has lists and resources, but it's a very specific treatment. It's not just don't do that, do this instead. It's more involved. When you say that's first line. You mean that's first that's your first choice before initiating a medication, exactly. But it's hard to find, and it's not always possible, and a lot of times kids don't want to do it, which, again, it's tricky, because if it's a treatment that you need to be active in, so if you're not going to do it, it's not going to work. And then you don't want to create an environment where the parents and the kids are yelling because the kid isn't doing the treatment to help the thing that's already hurting him, and it just turns into this like problematic mess, which, again, it happens, and you can work through it, but not everyone wants to do c bit. And so then we start thinking about tick medications. The first line medications we almost always use are alpha agonists, clonidine, guanfacine. Clonidine has a little bit more evidence than guanfacine, but no reason to not try both if one doesn't work. And what's also interesting and important, possibly from a pediatrician's point of view, is that the Alpha agonists are a lot more likely to work if there's co occurring ADHD, and we know that they're also a treatment for ADHD, and those are both involved in that circuitry. And so it's a little bit of a two birds, one stone, but the other really, really, really, really important takeaway, again, a lot of kids have ticks, have ADHD. You can use stimulants to treat the ADHD. It used to be said that if there's ADHD and ticks don't use stimulants, it'll worsen the ticks. Does it in a percent? Probably, yeah, but in huge studies, not more than placebo and or not for more than a very brief period of time, and in studies that combined Alpha agonists and stimulants for kids with ADHD and ticks, they did the best, and kids in the combo group, the alpha agonist group and the stimulant group all did better, or at least not worse, I think, even better than placebo for ticks. So that is so interesting, because that was always my teaching. If you give a child with ADHD a stimulant who already has ticks, you're likely to make the tics worse, and that's something that you have to make the parents aware of, right? So what you're saying is that we should not be dissuading them from a stimulant if that really is the best medication for them, exactly like it still might be worth trying clonidine first if there's ticks and ADHD, but if it's clearly the ADHD is the issue, yeah, you don't want to not use a stimulant for concern of ticks. And I'm curious about c bit. Do you have any statistics on the likelihood of it improving the TIC symptoms? Yeah, yeah, but improving the tics, at least in the moment, because, again, like new ticks might come and go, but the principles will be the same, but it, oh, gosh, this, it's, I think it's the effect size is around one, 1.2 what I can say is that after alpha agonists, the next line, this is where we need more medication and better medication with low side effects and high efficacy. And there's some coming down the pipeline that I'm really excited about. But after that, it's antipsychotics, dopaminergic agents, things like our trip resolve, or spheridone and CBIT is shown to work equally to those when done well and between the two, does one have more staying power? For example, I wonder if treating with a medication is just a band aid, or does it actually fix the ticks? I would say none of them fix the ticks, because, in general, like, none of our treatments are, like, quote, unquote, like disease modifying, but it's and there has to be better studies, or more studies, on whether they combine. It's tough to imagine combining wouldn't be helpful, but they haven't done all their research to officially. Say that I do think CBIT is great, just in terms of strengthening like probably helps with I can't say that either whether it helps with executive functioning or not, but in general, you're teaching yourself tools that you can use, that I'm sure are only helpful. But it's not that it would necessarily prevent new ticks from coming. You would just be able to use those strategies similarly with like clonidine and those medicines. It's not that they're going to stop new ones from coming, but you still might have that as a suppression. I guess a big question that comes up for me a lot in clinical practices, parents want to know, when should they be making these interventions? Yeah, and I've always learned with CBIT, for example, what I've learned, and I'm curious your thoughts on this, it's most effective when then, when there is that premonitory urge, when they know that the tick is going to happen and they have the ability to make a change in place of that tick. Is that your thought as well? I would say on the whole, it's certainly much more helpful. But also, even if they don't have that's what they would do with the therapist the work in terms of understanding what those triggers are. So that's why it's helpful, but I'd say not necessary, and I wouldn't recommend CBIT. If the kid has mild ticks and isn't bothered again, it's we don't have evidence that doing that is going to change the course. It'll help in the moment, if it's helping, and if the tics are bothering someone. But it's not that if you get them into treatment. We know that's more modifying as I think about it, as we're talking about this, the most common scenario I see is that the child really isn't bothered by it, but the parent is bothered. Yes, so you're saying that in that situation, the CBIT may be helpful, but not as helpful. Should the child be the motivating factor to starting the CBIT therapy Exactly? If the parent is bothered and the child isn't, I would not recommend CBIT, because you're setting yourself up for problems down the line, and they might get better on their own, and they should well. Thank you so much. This has been so helpful. Just to close any last words of reassurance that you'd like to offer, yeah, on the whole I always say the parents time is on your side with tics. The older you get, in general, the better they tend to get. And most kids with tics are doing well. They're doing fine. The more we react to them, the harder we can make it. And then lastly, I'd say ticks are something that a child has not who they are, and just acceptance to is often best, both for the kid, for the relationship, for the future. Thank you so much. And can parents see you if they, you know, if they're in New England? Yes, if they, we have a bit of a wait list, and we have a group, which is awesome, but yeah, if you go to the Mass General website and either Google my name or, like, Ped psych tics, our program should come up. And then there's always an intake that they can fill out and then see me or one of our great clinicians, Dr Greenberg, thank you so much. This has been such wonderful information, and I so appreciate your time. Thank you for coming on your child as normal. Yeah, you're welcome. Thank you for having me. Thank you for listening, and I hope you enjoyed this week's episode of your child is normal. Also, if you could take a moment and leave a five star review, wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask dr, Jessica.