Dealing with Tics
Because so many younger children and preteens with OCD also suffer from the tics associated with Tourette's syndrome (TS), it's important for you as a parent to know about this disorder because its symptoms may also be present in your child.
Tourette's syndrome is characterized by involuntary movements, motor tics, and involuntary sounds, vocal tics. These sounds and movements may not be bothersome to your child, or it's possible that his tics are so much a part of your child's demeanor that neither of you recognize them as symptoms of a disorder.
However, for many young OCD sufferers, tics are a cause of embarrassment and a barrier to social interaction. Some say they exhaust enormous energy on a daily basis to try and hide their tics from others, often without success. Three quarters of those suffering from TS are male. Some common tics include:
A head or eye twitch
A jerking arm, the motion and its negation
A sniff, blink, swallow, or foot tap
A word or statement repeatedly shouted out
A burp, oink, or part of a word
Verbalizations such as those above are tics when they are involuntary and reoccurring in the same way as the physical tics operate, for example, as involuntary movements. Many young people with OCD will also use “tic” as shorthand for an even wider range of OCD compulsions.
Tics and Shame
Many children with tics view these involuntary actions and verbalizations as mistakes. The child carries a lot of shame because he believes his tics are something he should be able to will away. Exposure exercises can be used to dampen the high levels of anxiety that accompany tics, but it's important that your child understands that tics are not mistakes; tics result from the same OCD that causes his other symptoms.
As such, they are things his brain and body cannot control. Your child may or may not decide to explain his tics to friends or teachers. But you may wish to point out to your child that this kind of openness with people he encounters on a daily basis often works to his advantage by getting those people on his side.
Too Much Touching
One behavior associated with Tourette's syndrome and OCD, which is sometimes defined as a tic, is the nearly constant need of some children to touch things, often in a ritualistic manner. One boy with a touching compulsion couldn't walk through the school hallway without putting his hand on the top right corner of every locker. Another child had to touch things that caused him pain, including stove burners and straight pins. For many children, these touching tics can be alleviated or eradicated through the use of ERP exposure exercises.
Although they affect older children as well, touching compulsions are especially common in younger children with OCD. Here is one mother's account of her son's touching compulsion, and another mother who watched her daughter's incessant touching turn into a “just right” ritual.
We noticed my seven-year-old son's frequent touching started after the death of his grandmother. He wanted to touch his father and me — all the time. At first I thought it was just to ask for reassurance. But it's been a year and it's gotten worse, and there are other OCD symptoms, too. We've started to work with the CBT by having him limit the number of times he touches us.
My daughter Tiffany always has to touch people or things a certain way, and if she doesn't think she's done it right, she'll do it over and over again. She used to do the same thing with doors. If she didn't walk in or walk out in the correct manner, she'd have to go back in or out until she got it “just right.” This is what showed me that rituals don't go away, one just changes into another.
Given the clinical name trichotillomania, hair pulling is a compulsive activity (like hand washing, ordering, and counting), which occurs within the OCD spectrum of behaviors. A 2005 study at Harvard McLean Hospital showed that hair pulling tends to affect females and younger children with more severe cases of pediatric-onset OCD. Those with comorbid hair pulling are also likely to have tics.
Hair pulling is often one of the least conscious compulsive actions — many young children are completely unaware they are doing it. Since it, too, is a reaction to anxiety, the best way to approach it is by attempting to find the trigger for the child's anxiety. Does she have a contamination fear in the classroom? Is she worried about having to speak in class? These are the sorts of triggers to help her locate and attempt to deal with through exposure exercises.
Our daughter who is five was diagnosed with trichotillomania when she was three years old and just starting nursery school. I noticed when she stopped pulling her hair, she started incessant talking, specifically, counting everything in sight, all the time.
This OCD symptom affects boys and girls equally and often begins in childhood. Like hair pulling, the younger child tends to have less conscious awareness of her compulsive skin picking. Here a mother connected her daughter's compulsive skin picking to the start of a new school year when her daughter was to enter the seventh grade.
It's back-to-school time and my child's OCD and skin picking is back in full force. There are new sores on her face, and on her neck and arms. One way I've dealt with it is to have her wear long sleeves. But then she tried to stay home from school, and when I wouldn't permit that, she screamed and cried. I think she can get through it if she hangs in there, and I'm trying to work with the teacher to lessen the stress with breaks from class and early dismissals.
From Amy Willensky comes this description of skin picking as a symptom of her comorbid OCD and Tourette's syndrome, from Passing for Normal:
There are still days when I want to rip off my fingernails or sit on my hands to keep from making an initial gratifying gouge…. [When] I imagine my body as a skinned tomato.
A child's skin picking is often among the first OCD symptom that a parent notices. If you observe a young child skin picking, monitor her closely. She may attempt to hide it from you, and she may well have some shame and embarrassment about her sores and raw skin. Tread carefully, and always let your child know you are on her side.