When your child has tics and OCD

If your child has both Tourette's/Tics and OCD, you have probably watched and wondered, "Which is it?" It is common to feel confused or unsure and there's a very good reason for it. We routinely see at least half of people with Tourette's/Tics also receive a diagnosis of OCD at some point in their lives (Hirschtritt et al., 2015) and even more show behaviors that are clearly compulsive, but don't look like tics. The two can look very similar from the outside, but often feel quite different from the inside.

You might see your child touch or tap furniture, rub their leg, or repeat some other movement and get upset/agitated when they are interrupted. They may ask repetitive questions that you are sure you've already answered, but become distressed if you don't answer again. Maybe you've been told "Don't interfere with their tics, just carry on like nothing is going on" (which is good advice), but you've also heard "Don't indulge or accommodate compulsions." As a loving parent, you're then left wondering, "Well, what should I do?!"

Knowing what is underneath can help you respond and often the label matters less than you'd think. The clearest difference is usually what comes right before the behavior and what happens after...

Tics, "Just right" or Tourettic-OCD, or "Classical" OCD

What it looks like?

• Tics: Sudden, repeated movements or sounds that serve no outside purpose
• T-OCD: Touching, tapping, evening up or repeating until it feels right
• Compulsions: repeated actions or mental rituals

What comes first?

• Tics: An uncomfortable physical urge, a bit like an itch or tension
• T-OCD: A sense that something is not "just right" yet
• Compulsions: Unwanted thoughts, images or urges that cause distress

What is it for?

• Tics: Releasing the urge, not preventing something bad
• T-OCD: Making it finally feel right
• OCD: Usually easing anxiety or getting certainty, though not always

Most people with tics notice a sort of physical urge/discomfort/sensation before the tic (called a "premonitory urge"). In one study, 93% of people with tic disorders reported feeling urges before their tics, and 84% said the tic brought a feeling of relief (Leckman, Walker & Cohen, 1993). Additionally, many people with Tourette syndrome and OCD repeat actions until they feel "just right" (Leckman et al., 1994). Clinicians sometimes call this Tourettic OCD. It may include a variety of "just-right" types of behaviors, including touching, tapping and repeating things to relieve discomfort rather than prevent a feared outcome (Mansueto & Keuler, 2005). Though Tourettic OCD is not yet formally recognized in the DSM-5, research and clinical anecdotes strongly support it as something sitting between classical tics and classical OCD.

Where it gets complicated

Five things make the line between tics and OCD blurry in real life:

1. Complex tics. Some complex tics overlap with compulsions. The same touching or blinking can release a physical urge, or it can ease a fear (Ferrão et al., 2009).
2. "Just right" experiences. As above, the need for things to feel right shows up in both Tourette's and OCD.
3. Avoidance and refusal. A child may avoid a place or refuse a task because tics get in the way, because of fear or embarrassment, or because of OCD, anxiety or other difficulties. In a survey of adults with tic disorders, nearly half had skipped social events or going to public places because of tics, and the authors raised the possibility that this avoidance may be tied to OCD, anxiety or ADHD (Conelea et al., 2014).
4. They may sit on a continuum. Researchers describe tics and compulsions as possibly lying on a continuum, and people with both OCD and tics often have features in between (Ferrão et al., 2009).
5. Holding it back is not the same as choosing it. Many children can hold back a tic for a while. That doesn't mean the tic is simply a choice. Most people with tics describe them as a response to an uncomfortable urge (Leckman, Walker & Cohen, 1993), and holding them back tends to make the urge build (Capriotti et al., 2014).

So it is not always clear which is which. And maybe that is not the most important thing.

The cycle that keeps both going

Tics and OCD often run on the same engine: relief!

1. First there is an uncomfortable feeling: For tics, a quasi-physical urge. For OCD, fear, doubt or a "not right" feeling.
2. The behavior brings relief: The tic relieves the urge. The compulsion eases the anxiety for a moment...
3. That feeling of relief teaches the brain to do it again! Experiments with children who have tics have shown that relief from the urge helps keep tics going (Capriotti et al., 2014).

Families can get pulled into the OCD side of this cycle without meaning to - Answering the same question again, accommodating rituals, or changing routines to avoid distress... These all bring short-term relief (for the child and the parent). In one study of children with OCD, this kind of family accommodation was common, and the more severe the symptoms, the more accommodation emerged (Storch et al., 2007). That is not a failure on your part, it is just what loving parents do when their child is in distress.

Function first: what is this behavior for?

Instead of starting with "Is this a tic or OCD?", start with "What is this behavior doing for my child?"

Clinicians call this looking at the function of a behavior. The same action can serve very different purposes, and the knowing the purpose can help us find a more helpful response.

Stop, collaborate and listen.

1. Pause your own reaction. A calm few seconds keeps your worry or frustration from becoming part of the pattern.
2. Look at what happens before and after. What was going on just before? What changed right after? Did the urge ease, did a worry settle, did a demand go away, did someone get involved?
3. Ask what might be driving it. The most common possibilities are:
   • A tic: an urge, released by movement or sound.
   • A compulsion: a fear, doubt or "not right" feeling, eased by the ritual.
   • Avoidance: getting out of something hard or scary.
   • A skill gap: your child feel they can do what is being asked.
   • Big emotions: your child is overwhelmed and can't settle yet.
4. Ask your child what they think is happening. They can be a great collaborator. Ask what they feel just before, and what would happen if they didn't do it. Their answer is often the best clue you have.

Often more than one thing is happening at once - That is fine (and normal)! Naming the possibilities is what lets you respond to each one intentionally rather than reacting in the moment.

What you can do this week • Pick one behavior to watch. For a few days, jot down what came just before and just after. • Notice the relief. Whose discomfort ends when the behavior happens, your child's, yours, or both? • Notice your part in the cycle. If you are answering the same question or joining a ritual, that is worth raising with your child's clinician. • Don't treat holding back as proof of choice. If your child can stop a tic for a while, that tells you about effort, not control. • Ask about evidence-based care. CBIT for tics and CBT for OCD are well studied. A clinician who knows both can help you sort out which is which, and what to do about each.

This overall approach also matches how evidence-based treatments work for Tourette's/Tics and OCD. Comprehensive Behavioral Intervention for Tics (CBIT) includes a function-based part that looks at the situations and reactions that make tics worse. In a randomized trial it helped about half of children experience significant improvement in tics (Piacentini et al., 2010). The American Academy of Neurology guideline lists CBIT as a first-line treatment for tics (Pringsheim et al., 2019).

References

1. Capriotti, M. R., Brandt, B. C., Turkel, J. E., Lee, H.-J., & Woods, D. W. (2014). Negative reinforcement and premonitory urges in youth with Tourette syndrome: An experimental evaluation. Behavior Modification, 38(2), 276–296. https://doi.org/10.1177/0145445514531015
2. Conelea, C. A., Busch, A. M., Catanzaro, M. A., & Budman, C. L. (2014). Tic-related activity restriction as a predictor of emotional functioning and quality of life. Comprehensive Psychiatry, 55(1), 123–129. https://doi.org/10.1016/j.comppsych.2013.06.009
3. Ferrão, Y. A., Miguel, E., & Stein, D. J. (2009). Tourette's syndrome, trichotillomania, and obsessive–compulsive disorder: How closely are they related? Psychiatry Research, 170, 32–42. https://doi.org/10.1016/j.psychres.2008.06.008
4. Hirschtritt, M. E., Lee, P. C., Pauls, D. L., et al. (2015). Lifetime prevalence, age of risk, and genetic relationships of comorbid psychiatric disorders in Tourette syndrome. JAMA Psychiatry, 72(4), 325–333. https://doi.org/10.1001/jamapsychiatry.2014.2650
5. Leckman, J. F., Walker, D. E., & Cohen, D. J. (1993). Premonitory urges in Tourette's syndrome. American Journal of Psychiatry, 150(1), 98–102. https://doi.org/10.1176/ajp.150.1.98
6. Leckman, J. F., Walker, D. E., Goodman, W. K., Pauls, D. L., & Cohen, D. J. (1994). "Just right" perceptions associated with compulsive behavior in Tourette's syndrome. American Journal of Psychiatry, 151(5), 675–680. https://doi.org/10.1176/ajp.151.5.675
7. Mansueto, C. S., & Keuler, D. J. (2005). Tic or compulsion? It's Tourettic OCD. Behavior Modification, 29(5), 784–799. https://doi.org/10.1177/0145445505279261
8. Pediatric OCD Treatment Study (POTS) Team. (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA, 292(16), 1969–1976. https://doi.org/10.1001/jama.292.16.1969
9. Piacentini, J., Woods, D. W., Scahill, L., Wilhelm, S., et al. (2010). Behavior therapy for children with Tourette disorder: A randomized controlled trial. JAMA, 303(19), 1929–1937. https://doi.org/10.1001/jama.2010.607
10. Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896–906. https://doi.org/10.1212/WNL.0000000000007466
11. Storch, E. A., Geffken, G. R., Merlo, L. J., Jacob, M. L., Murphy, T. K., Goodman, W. K., Larson, M. J., Fernandez, M., & Grabill, K. (2007). Family accommodation in pediatric obsessive-compulsive disorder. Journal of Clinical Child & Adolescent Psychology, 36(2), 207–216. https://doi.org/10.1080/15374410701277929