What causes tics? How the pandemic, stress, and social media play a role.

Every year, children and their parents seek medical care for tics. These involuntary, repetitive verbal expressions and physical behaviors are often caused by the neurologic condition Tourette syndrome. Typically, symptoms begin when children are between the ages of five and seven. Boys are more likely to be diagnosed with the condition.

But during the pandemic, physicians around the world noticed something unusual: Adolescent and teen girls began showing up in emergency departments exhibiting tics that developed seemingly out of nowhere and were not related to Tourette syndrome. Doctors shared details with each other about the surprising phenomenon and took note of something even stranger. Patients had picked up the same tics, regardless of where they lived. They repeated random words or phrases, like “flying shark,” “beans,” and “woo-hoo,” in addition to saying the same obscenities. They clapped their hands and pointed their fingers, and hit or banged parts of their body as well as other people or objects.

The doctors soon identified a common thread tying these cases together: viewing of viral TikTok videos featuring creators with Tourette syndrome. The #tourettes hashtag on the social media platform has 5.5 billion views.

Sleuthing by doctors offered some insights about the phenomenon, but the U.S. Centers for Disease Control and Prevention recently published data illustrating its scale. The mean number of weekly visits to the ER for tics skyrocketed for adolescent girls from about a dozen prior to the pandemic to 85 at its peak in 2021. While that number began to decline toward the end of the year, it surged at the start of 2022. In general, the proportion of visits for tic disorders tripled during the pandemic. Visits for children’s mental health conditions, like anxiety, disordered eating, and obsessive-compulsive disorders, rose markedly during the same time. The CDC noted in its report that pandemic stress or exposure to severe tics on platforms like TikTok might explain the unexpected cases.

Dr. Mohammed Aldosari, a pediatric neurologist and director of the Cleveland Clinic’s Center for Pediatric Neurosciences, says it’s critical to offer teens, parents, and caregivers reassurance that such tics are treatable, and rarely a symptom of a more dangerous or life-threatening disorder.

“Mostly this is an expression of extreme stress, whether it’s recognized or unrecognized by the parents,” says Aldosari, who has treated patients experiencing the sudden onset of tics during the pandemic. “Something is stressing this young teenager.”

What causes tics in children?

Along with other experts, Aldosari believes social media may be the catalyst for the sudden onset of tics, rather than the cause. In one published account of the phenomenon, from November 2020, doctors in the United Kingdom described a 14-year-old girl with no history of tics who started exhibiting complex head turns, neck thrusting, and flailing, along with making yelping noises, the day after a COVID-19 lockdown announcement. The restrictions, changes to routine, social media exposure and bullying, and pandemic-related stress all factored into the girl’s diagnosis.

The doctors wrote that stress may be unmasking a predisposition to tics in some patients. For others, it could be compounding existing vulnerability to anxiety, or other underlying neurological and emotional difficulties, to the point where patients become totally overwhelmed.

Aldosari says that for some people stress can trigger a movement disorder, including the types of involuntary tics that are not caused by Tourette syndrome. In such cases, the brain is trying to physically express a feeling of overwhelm. It makes sense that teens, many of whom couldn’t find social and athletic outlets for stress during periods of the pandemic, might experience tics as a result. The most vulnerable teens might also be susceptible to viral videos of young people demonstrating their tics or tic-like behaviors and then unwittingly adopt them, says Aldosari.

How to help a child with tics

Youth who experience involuntary tics — and their parents — should remember that these expressions and movements aren’t fake or attention-seeking. Instead, they’re an indication of significant distress that can be treated with help from a medical professional. At first, teens might not be aware of, or eager to discuss, how stress affects them.

Aldosari says patients should see a psychologist who can help them understand what contributed to their development of tics. He also notes that an evaluation of symptoms shouldn’t require expensive or intensive procedures like magnetic resonance imaging or a battery of blood tests, which is what some physicians ordered for their patients when the phenomenon first emerged during the pandemic.

Treatment involves addressing both the involuntary movements and vocalizations, as well as their underlying causes, like stress and anxiety. Cognitive behavioral-based therapies, which help patients identify how thoughts influence their feelings and behavior, can reverse or diminish tics. If a teen is diagnosed with a severe mental illness that’s gone undetected so far, treatment might also involve antidepressant or antipsychotic medications. Tics that developed in conjunction with social media use may improve when a patient reduces their exposure to it.

In the United Kingdom case study, the doctors noted that teen girls with tics posted content about their behaviors, which had notable benefits and drawbacks.

“They report that they gain peer support, recognition and a sense of belonging from this exposure,” wrote the doctors. “This attention and support may be inadvertently reinforcing and maintaining symptoms.”

Aldosari says that if teens and their parents want to prevent tics, they should be mindful of stress and unmediated social media use, particularly tic-related content. Teens experiencing headaches, sleep issues, social withdrawal, and conflicts with friends and family should consider those challenges as indicators that stress is taking a toll, whether they realize it or not.

The increase in tic disorders and other mental health conditions during the pandemic is just the “tip of the iceberg,” says Aldosari. For every teen who sought medical treatment at the ER, there are likely several others who contacted their physician or haven’t even received any care and therefore don’t show up in official statistics.

Aldosari says it’s critical to intervene quickly when symptoms begin: “Early recognition [and] early help could prevent a downward spiral.”

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