Wednesday 15 August 2018

Dear David Coleman: My son (7) has vocal tics and now the family are 'ssshing' him. Can you help?

(Stock photo)
(Stock photo)
David Coleman

David Coleman

Clinical psychologist David Coleman offers parenting advice in his weekly column.

Q. Our seven-year-old son developed a verbal tic last year. We have gone down different routes such as GP, psychologist, paediatrician and allergist. We have changed his diet and encouraged more sporting activities. He is doing well in school and we have a very supportive teacher. However, it is having a huge impact on the family and extended family with various family members looking for more medical examinations and doing a lot of "ssshing" him. I'm finding it really difficult because I don't know how best to support him. Please can you help?

David replies: Verbal tics, sometimes called vocal tics, are completely involuntary and usually unconscious sounds that a child or adult will make. You don't mention the nature of the verbal tics, but often they are things like a repetitive and unnecessary cough, a nasal sniffing, humming or words said or shouted.

When those tics occur in tandem with behavioural tics (like facial grimaces, blinking and so on) they may fall into the realm of Tourette's syndrome. Sometimes parallels are drawn between tics, OCD and trichotillomania (hair-pulling). I think this is because of the subconscious and apparently involuntary nature of all of them.

In truth, most tics are best ignored and they tend to go away of their own accord. Most children with tics don't need, or get, any kind of treatment. The tics are not usually an indication of anxiety, although they may be exacerbated if the child is in a stressful environment.

It sounds like you have already made many efforts to try to reduce your son's tics. I assume that none of them have been helpful since you are now contacting me. I'd be interested to know whether the advice you have received has been consistent, or have you been left with competing suggestions for how to deal with it?

In my view, unless the tics are very distressing for your son, or are very disruptive in school, you might be best to leave well enough alone. By drawing his constant attention to the tics you are unlikely to be helping him to avoid making the sounds.

In my understanding, the experience for a child of trying to avoid making a tic is like you or I trying to avoid reacting to the tickling sensation at the back of our nose that inevitably results in a sneeze.

So, when children are repeatedly told to stop making the tics (or being told to shush), they could end up feeling really bad, guilty or like a failure, since they can't help it without some kind of strategy.

There is a behavioural strategy, called Habit Reversal Therapy (HRT) that children can try to implement. Essentially, as the name suggests, the therapeutic approach operates on the basis that the vocalisation is a habit. The process of changing it is to become aware of the signs or indications that the vocalisation is about to be made, and then to introduce a competing, or blocking behaviour, to redirect yourself from making the vocal tic.

So, in your son's case he would first need help to become fully aware of any pre-cursors to the tic sounds (for example an awareness that he is drawing in breath before vocalising, or that there is some physical change in his face, throat or body that might alert him).

Then, when he is aware that the tic may be about to happen, he can try to do something different instead of just following through with the tic as usual. With vocal tics the alternatives are often something like taking a long slow, mindful, breath, or a gentle swallow.

However, in order to be able to achieve any change by this method, your son needs to be very motivated, as it will require a sustained effort to be able to change the habit. He will also need to feel supported, rather than criticised, for the inevitable tics that will slip past him unnoticed.

Perhaps your most effective support for him can be to protect him from the family, extended and immediate, who keep having a go at him for something he currently doesn't have control over. Maybe telling them to back off might lead to less stressful environment where he can more successfully address the tics.

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