Tics are sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations that can range from simple to complex. Tics are the defining symptom of Tourette syndrome and other tic disorders that often emerge in childhood. For many children, tics tend to worsen during the preteen and teenage years when puberty starts. Puberty is a time of many physical and hormonal changes that can exacerbate tics. However, there are treatments available to help manage tics during the teen years.
What are the causes of tics?
Tics are caused by abnormalities in certain areas of the brain including the cortex, thalamus, and basal ganglia. These areas help regulate coordinated movements and inhibition of unwanted movements and vocalizations. Dysfunction in these parts of the brain leads to difficulty suppressing sudden urges to make sounds or gestures that result in tics.
The exact cause of tic disorders is unknown but likely involves a combination of genetic and environmental factors. Studies suggest abnormalities in several neurotransmitters including dopamine, serotonin, acetylcholine, GABA, and glutamate may contribute to excess excitability in brain circuits that generate tics.
How do hormones impact tics?
Puberty onset usually begins between ages 8-14 in girls and ages 9-15 in boys. This stage of development is marked by increased production of hormones including testosterone, estrogen, progesterone, growth hormone, and adrenal hormones. These hormonal surges lead to growth spurts and development of secondary sex characteristics.
Research indicates hormones likely aggravate tics during puberty through effects on brain regions that regulate motor function and inhibition. Studies have found testosterone exacerbates tics in adolescents with Tourette syndrome. Estrogen fluctuations during the menstrual cycle also appear to worsen tics in some females. The hormonal changes of puberty are believed to further disrupt already compromised neurocircuitry involved in suppressing unwanted motor and vocal tics.
At what age are tics most severe?
Tics tend to follow a “waxing and waning” course over time. Tics emerge in childhood, usually around 5-7 years old, and worsen in severity and frequency between 10-12 years old coinciding with the beginning of puberty. However, the peak severity of tic symptoms tends to occur between 12-15 years old when hormone levels surge during puberty. After this peak, tics often improve into late adolescence and early adulthood.
One study that followed children with Tourette syndrome over 13 years found:
- Average age of tic onset: 6.4 years old
- Average age of peak tic severity: 11.7 years old
Other studies have also noted the preteen and early teen years tend to be when tics are at their worst.
What symptoms get worse with puberty?
Both motor and vocal tics typically intensify during puberty. Some examples of motor tics that may increase include:
- Eye blinking
- Facial grimacing
- Head jerking
- Shoulder shrugging
- Arm thrusting
- Leg kicking
- Finger flexing
- Complex tic sequences like jumping and twirling
Vocal/phonic tics that may get worse during puberty include:
- Throat clearing
- Sniffing
- Grunting
- Barking
- Tongue clicking
- Coprolalia (inappropriate words or swearing)
- Echolalia (repeating words of others)
- Palilalia (repeating own words)
In addition to an increase in tic frequency and intensity, adolescents often develop more complex motor tics during puberty involving larger muscle groups and purposeful-appearing movements. Adolescents may also experience the emergence of problematic vocal tics like coprolalia.
Why is tic control harder during puberty?
Puberty appears to make suppressing tics more difficult through several mechanisms including:
- Hormonal effects on the brain – Rising hormone levels may exacerbate dysfunction in cortico-striato-thalamo-cortical circuits involved in motor control and inhibition.
- Maturation of the brain – The prefrontal cortex involved in executive functioning like inhibition continues developing during adolescence which can make suppressing urges to tic more challenging.
- Heightened stress and emotions – Puberty is an emotionally charged time which can worsen tics. Stress and intense emotions often increase tic severity.
- More self-consciousness – Increased self-awareness and social pressures during the teen years causes many youth to feel more embarrassed or anxious about their tics which can paradoxically make them worse.
- Rebellion against suppression – After years of trying to suppress their tics, adolescents may rebel against this and intentionally stop inhibiting their tics.
Do OCD and anxiety symptoms also worsen?
Many individuals with chronic tic disorders also have co-occurring obsessive-compulsive disorder (OCD) and anxiety disorders like generalized anxiety disorder or social anxiety disorder. OCD and anxiety symptoms likewise tend to worsen with the onset of puberty as hormones, brain development, emotions, and social pressures converge.
Studies indicate youth with Tourette syndrome and OCD experience intensification of both their tics and OCD symptoms during puberty. Those with tic-related OCD may develop worsened obsessions about symmetry, ordering, arranging, counting, and repeating as well as heightened compulsions for activities like evening-up, ordering, checking, and ritualizing.
How long do puberty-related tic changes last?
Every person is different, but in most youth, the substantial worsening of tics driven by puberty lasts around 2-4 years. Tics often remain at their peak severity through ages 12-15, followed by slow but steady improvement into late adolescence and early adulthood.
In a minority of individuals, severe tics persist after puberty. About 10-20% of people continue to experience pronounced tic symptoms into adulthood that cause substantial impairment in daily functioning.
Will tic medication dosages need to increase?
Many youth with chronic tic disorders take medication to help reduce tic frequency and intensity. Commonly prescribed tic medications include:
- Clonidine
- Guanfacine
- Topiramate
- Alpha agonists (clonazepam, lorazepam)
- Antipsychotics (risperidone, aripiprazole, haloperidol)
As puberty drives worsening of tics, children often require higher dosages of their tic medications or addition of new medications to regain control over their symptoms. Close monitoring by a doctor is recommended to ensure tic medications are adjusted appropriately to match the changing biology during adolescence.
Tic medication dosage changes with puberty
| Medication | Childhood dose | Adolescent dose |
|---|---|---|
| Clonidine | 0.05 mg 2x/day | 0.1 mg 2x/day |
| Guanfacine | 1 mg 1x/day | 2 mg 2x/day |
| Topiramate | 25 mg 2x/day | 50 mg 2x/day |
| Clonazepam | 0.25 mg 3x/day | 0.5 mg 3x/day |
| Risperidone | 0.25 mg 1x/day | 0.5 mg 2x/day |
When should a child with tics see a doctor?
Children and adolescents with chronic tic disorders should be under the regular care of a pediatrician, neurologist, or psychiatrist familiar with treating tic conditions. Tic symptoms tend to fluctuate over time, so frequent follow-up allows medication adjustments in response to tic severity.
Reasons to schedule an appointment with a tic disorder specialist during puberty include:
- Significant worsening of tics
- New vocal or motor tics developing
- Tics are causing physical pain or injury
- Tics are greatly interfering with school work
- Existing medication not providing enough tic control
- Significant increase in OCD/anxiety symptoms
- Onset of difficulties like depression or rage attacks
Seeing the doctor promptly when puberty exacerbates tics allows quick medication changes so that symptoms do not spiral out of control and negatively impact a child’s functioning and wellbeing.
What self-help strategies help during puberty?
In addition to medications, various self-help strategies and behavioral therapies can aid tic management during adolescence:
- Habit Reversal Training – Using competing muscle tensing or mental focusing exercises when urge to tic arises.
- Relaxation techniques – Deep breathing, progressive muscle relaxation, yoga, mindfulness meditation.
- Reduce stress – Get enough sleep, take breaks, add enjoyable activities.
- Exercise regularly – Aerobic exercise and sports helps relieve tics.
- Avoid tic triggers – Identify and limit exposures to factors that worsen tics like heat, excitement, fatigue, stress.
- Suppress consciously – Use cognitive behavior therapy techniques to consciously suppress tics.
- Don’t “cave in” – Avoid releasing all tics as once as this reinforces the behaviors.
Such behavioral approaches can be very helpful when combined with tic medications. A psychologist can provide therapy focused on developing coping skills to better manage the many challenges of adolescence with a tic disorder.
What is the outlook for tics after puberty?
While puberty poses a difficult time for those with Tourette syndrome and other chronic tic conditions, the long-term outlook is generally positive. Most adolescents experience gradual improvement in their tic symptoms by late adolescence. Tics tend to become less frequent, less intense, less complex, and more controllable over time.
Studies looking at the future course of Tourette syndrome have found:
- About 85% of cases improve by late adolescence.
- Tic severity continues declining for most in their 20s.
- By early adulthood, about 40% experience complete tic remission for at least 1 year.
- Those with milder tics before puberty tend to see greater improvement.
While puberty poses challenges in terms of tic severity, most youth can expect decreasing symptoms and interference over the next several years as their hormones stabilize and neurocircuitry supporting executive control matures.
Conclusion
Puberty marks a vulnerable period for children with chronic tic disorders like Tourette syndrome. The hormonal fluctuations and brain changes of adolescence frequently intensify both motor and vocal tics. Tic worsening typically begins around 10-12 years old and peaks in severity between ages 12-15 for most youth. In addition to tics, OCD and anxiety symptoms often worsen during this time as well. While tic severity may necessitate medication adjustments and more vigilant monitoring during puberty, this period of intensification is usually temporary. By carefully managing tic symptoms and using behavioral approaches during adolescence, most youth can expect gradual improvement in their condition through late adolescence and into adulthood.