Why Is My Child Doing That?
Motor Tics, ADHD, PANDAS & Everything in Between
A comprehensive guide to understanding tics in children with ADHD — what causes them, what makes them worse, what makes them better, and when to worry.
The Moment You First Notice It
You’re sitting at the dinner table and your child blinks. Not a normal blink. A hard, squeezing, repetitive blink that makes you look twice. Or maybe it’s a shoulder shrug that keeps happening during homework. A head jerk during car rides. A sniffing sound that won’t stop even though they don’t have a cold.
Your stomach drops. You Google it. And suddenly you’re three tabs deep into Tourette’s, PANDAS, neurological conditions, and medication side effects, feeling more panicked with every click.
Take a breath. I’ve sat with thousands of parents in this exact moment over twenty-five years of practice. Most of the time, what you’re seeing is far more common, far more manageable, and far less frightening than the internet would have you believe.
By the end of this guide, you’ll understand what tics actually are, why they travel alongside ADHD, how they change at different ages, how to tell them apart from other conditions, the full truth about PANDAS, and exactly what to do. No panic required.
What Are Tics, Really?
A tic is a sudden, rapid, involuntary movement or sound. Your child doesn’t choose to do it. They may not even realise they’re doing it. Think of it like a sneeze — you can sometimes feel it coming, you might be able to hold it back briefly, but eventually it has to come out.
Types of Tics
Simple motor tics are brief, single movements involving one muscle group. Eye blinking is the classic one. Shoulder shrugging. Nose wrinkling. Facial grimacing. Head jerking. Mouth movements. These are the ones parents usually notice first.
Complex motor tics involve more coordinated, purposeful-looking movements. Touching objects in a particular way. Jumping. Twisting. Complex hand gestures. These can look deliberate, which is why parents sometimes think their child is “doing it on purpose.” They’re not.
Vocal tics are sounds produced involuntarily. Throat clearing is the most common — so common that parents often take their child to the GP for repeated “throat infections” before anyone considers a tic. Sniffing. Grunting. Coughing. Humming. In rare cases, words or phrases. The dramatic swearing you’ve seen on television (coprolalia) occurs in fewer than 10% of people with Tourette syndrome. It is not the norm.
Your child isn’t doing this to annoy you. Their brain is sending signals they can’t fully control. Telling them to “stop it” is like telling them to stop sneezing. Understanding this single fact changes everything about how you respond.
The Waxing and Waning Pattern
This is something that catches many parents off guard. Tics don’t stay at the same level. They naturally fluctuate — getting better and worse in cycles of roughly two to three weeks. One week the eye blinking is constant. The next week it’s barely there. Then it returns, perhaps as a shoulder shrug instead.
This pattern creates enormous confusion. Parents change the diet, adjust medication, try a supplement — and the tic improves. They credit the change. But the tic was going to improve anyway. It was on the downswing of its natural cycle. Two weeks later, the tic returns, and parents feel like they’ve failed.
Understanding the wax-and-wane cycle is essential. It means you need to observe over weeks and months, not days, before drawing conclusions about what’s helping and what isn’t.
Why Are Tics So Common in Children with ADHD?
ADHD and tic conditions share some common wiring. Both involve the same brain circuits — the pathways connecting the front of the brain (which handles planning and impulse control) with deeper structures called the basal ganglia (which help control movement and habits). Both involve the chemical messenger dopamine, although in slightly different ways.
In ADHD, the front of the brain doesn’t get enough dopamine to do its job properly. That’s why your child struggles with the pause button, with holding things in mind, with stopping before acting.
In tic conditions, there’s actually too much dopamine activity in the movement-control parts of the brain. The circuits that should keep unnecessary movements in check aren’t filtering properly. Movements slip through that shouldn’t.
Because these circuits overlap, it makes biological sense that the two conditions often travel together. Research consistently shows that ADHD typically appears first — two to three years before tics emerge. So if your child was diagnosed with ADHD at six and develops tics at eight, that’s a well-documented pattern, not a coincidence.
If there’s a family history of tics on either side — a parent who cleared their throat constantly, a grandparent who had a facial twitch, an uncle who blinked excessively — your child’s risk increases. ADHD and tic conditions run in families, sometimes together. The same genes that contribute to ADHD also increase the risk for tics.
The Unmasking Effect — Why Tics Appear After Starting Medication
This is the question I hear almost every week: “We started ADHD medication and now he’s got tics. Did the medication cause this?”
In the vast majority of cases, the answer is no.
Before medication, your child was constantly moving. Fidgeting, bouncing, shifting, tapping, squirming. In all that movement, a small repetitive tic was invisible. It was lost in the background noise of general hyperactivity.
When ADHD medication reduces the overall movement, your child becomes calmer. Against this new, quieter backdrop, the tic that was always there suddenly becomes visible. Like hearing a dripping tap once the television is turned off. The tap was always dripping. You just couldn’t hear it over the noise.
Nine-year-old Alex developed noticeable eye-blinking tics shortly after starting ADHD medication. His parents were convinced the medication caused it. Careful history revealed that Alex had been clearing his throat and blinking excessively for months, but these movements were lost in his general hyperactivity. Once his overall movement decreased with medication, the tics became visible.
We continued the ADHD medication — which was helping enormously with his focus and behaviour. The eye blinking resolved on its own within six months. Alex continued to thrive academically and socially.
What Tics Look Like at Different Ages
Tics don’t stay the same. They change with your child’s development. Understanding this helps you know what to expect and when to be concerned.
Transient tics — ones that appear for a few weeks or months and then disappear — affect up to one in four children during early childhood. Simple motor tics like eye blinking or nose scrunching are most typical. They often go completely unnoticed because toddlers move so much anyway.
What to do: Nothing. Do not draw attention to them. Most will disappear within months. Saying “stop blinking like that” makes them worse.
The most common time for tics to become noticeable. Typical onset of tic conditions is between five and seven. You may see more variety — head jerking, shoulder shrugging, vocal tics like throat clearing and sniffing. Teachers may comment. Your child may become aware of their tics for the first time.
What to do: This is also when ADHD medication commonly starts, which is why the unmasking effect catches parents off guard. Don’t rush to blame the medication. Speak to the school. Monitor, but don’t overreact.
Tic severity typically reaches its peak here. This is when tics are most noticeable, most frequent, and most varied. Complex tics may appear. Your child may develop “premonitory urges” — a building sensation before a tic, like an itch that needs scratching.
This is the most challenging period. Your child is socially aware. They may be teased. Self-esteem takes a hit. The critical hope: for the majority, this is the worst it gets. From here, the trajectory is almost always improvement.
Roughly two-thirds of children see a substantial reduction in tic severity by mid-to-late teens. Some see tics disappear entirely. ADHD typically persists more stubbornly than tics. Your teenager may still struggle with attention and organisation long after tics have faded.
What to do: Continue ADHD management. Don’t assume “they’ve grown out of it” just because tics have improved.
If tics persist, they’ve usually stabilised at a milder baseline. Stress, fatigue, and illness can still temporarily increase tics, but most adults report that tics are a manageable part of life rather than a dominant feature.
The Comorbidity Map — When It’s More Than Just Tics
Here’s something that surprises most parents: when a child has both ADHD and tics, the tics are usually not the biggest problem. Research consistently shows that the other conditions travelling alongside — anxiety, OCD, learning difficulties, sleep problems — cause more impairment than the tics themselves. The tics are the most visible. They’re often not the most disabling.
Approximately 80% of children with ADHD have at least one additional condition. Not “some children.” The majority. The same genes that contribute to ADHD also increase risk for other conditions. The brain systems affected by ADHD overlap with systems that control mood, learning, sleep, and social processing.
Anxiety — The Invisible Amplifier
Anxiety affects 30–50% of children with ADHD, and has a particularly nasty relationship with tics. Anxiety makes tics worse. Worse tics make anxiety worse. The cycle feeds itself. Watch for: excessive worry, stomach aches without medical explanation, avoidance of situations, difficulty separating from you, perfectionism or complete task avoidance, and sleep difficulties.
OCD — The Unwanted Thought Patterns
Obsessive-compulsive traits are present in 30–50% of people with Tourette syndrome and are more common when ADHD and tics co-exist. In children, OCD may present as needing things to be “just right” — touching something with one hand then having to touch it with the other. Reading a sentence over and over. Needing symmetry.
Oppositional Behaviour
ODD appears in 40–60% of children with ADHD. A child who is constantly corrected — for not paying attention, for fidgeting, for ticcing — eventually pushes back against everything. Much of what looks like “deliberate defiance” is accumulated frustration. Treating the ADHD properly often reduces oppositional behaviour significantly.
Learning Difficulties
Learning disabilities affect 30–50% of ADHD children. When you add tics, the classroom becomes even harder. The child is managing attention (ADHD), suppressing tics (which takes enormous mental energy), and processing material differently (learning disability). By afternoon, they’ve got nothing left.
Depression — The Long Shadow
Depression affects 15–30% of ADHD children, climbing through adolescence. Years of feeling different, being corrected, and being teased take their toll. In children, depression often looks like irritability rather than sadness — making it easy to miss.
Sleep Problems
Up to 70% of children with ADHD have sleep difficulties. Poor sleep makes everything worse — tics, attention, mood, behaviour. The racing mind that can’t filter during the day doesn’t switch off at night. If tics seem worse after poor sleep, this connection is almost certainly at play.
Tics vs Stimming vs Habits — How to Tell the Difference
| Feature | Tics | ADHD Stimming | Habits |
|---|---|---|---|
| Control | Involuntary. Hard to suppress | Voluntary or semi-voluntary | Can be unlearned with awareness |
| Purpose | No clear purpose — neurological discharge | Self-soothing, focus, energy release | Comfort or habit loop |
| Examples | Eye blinking, shoulder shrug, throat clearing, grunting | Humming, pen clicking, foot tapping, muttering | Nail biting, hair twirling, lip chewing |
| Pattern | Waxes and wanes every 2–3 weeks | Triggered by boredom, excitement, or stress | Consistent, doesn’t fluctuate |
| Key Question | “Would they stop if they could?” Yes → likely a tic | “Does it help them focus or calm down?” Yes → likely stimming | “Is it automatic but can stop when aware?” Yes → likely a habit |
Is It a Tic or Petit Mal Epilepsy? — How to Tell the Difference
This is a question I’m asked more often than you’d think. A parent notices their child “zoning out” or making repetitive movements and wonders: is this a tic, or could it be a type of seizure?
Absence seizures (previously called petit mal epilepsy) can look remarkably similar to some tic behaviours, particularly staring spells and repetitive blinking. Getting this distinction right matters, because the treatments are completely different.
| Feature | Motor Tics | Absence Seizures (Petit Mal) |
|---|---|---|
| What it looks like | Sudden, brief movements — blinking, shrugging, head jerks. Child is aware during the movement | Sudden “blank stare” lasting 5–30 seconds. Child is completely unresponsive during the episode |
| Awareness | Fully conscious. Can respond if spoken to (even if annoyed) | Not conscious. Cannot respond, does not hear you. Will not remember the episode |
| Can you interrupt it? | Yes. Touch, voice, or distraction can interrupt. Child is aware of interruption | No. Nothing interrupts it. The child “comes back” only when the episode ends on its own |
| Duration | A fraction of a second to a few seconds | Usually 5–30 seconds. Sometimes longer |
| Frequency | Variable. Waxes and wanes over weeks | Can happen many times per day — sometimes dozens |
| Eyes | May blink rapidly, but eyes remain focused | Eyes may flutter or roll slightly upward. Gaze is “empty” |
| After the episode | Immediately normal. No confusion | Resumes activity as if nothing happened. May ask “What?” — lost the thread |
| When it happens | Worse with stress, fatigue, excitement | Can be triggered by hyperventilation, tiredness, or flashing lights |
| Premonitory urge | Older children (10+) may feel a building sensation before the tic | No warning at all. Completely sudden |
| Investigation | Clinical diagnosis. No test needed in most cases | EEG (electroencephalogram) shows characteristic pattern |
Request an EEG if your child shows: staring spells where they are genuinely unresponsive (not just daydreaming), episodes that cannot be interrupted by touch or voice, loss of the “thread” of conversation after an episode, episodes triggered by rapid breathing or flashing lights, or a sudden unexplained drop in school performance that doesn’t fit the ADHD pattern. An EEG is painless, non-invasive, and provides a definitive answer.
When your child seems to “zone out,” try this: call their name clearly and touch their arm. A child having a tic will respond immediately — they’ll look at you, perhaps irritably, but they’ll engage. A child having an absence seizure won’t respond at all. They’ll look through you. When the episode ends seconds later, they’ll rejoin the conversation as if nothing happened, often asking “What did you say?”
If you’re ever unsure, record the episode on your phone. A thirty-second video is worth more to your doctor than thirty minutes of description.
PANDAS — The Full Story
If you’ve Googled “tics in children,” you’ve almost certainly come across PANDAS. And if you’re like many parents I see, it’s either terrified you or given you false hope that you’ve found “the answer.” Let me give you the full picture.
PANDAS stands for Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. It is a condition where a strep infection — the same bacteria that causes strep throat — triggers an unusual immune response. In a small number of children, the body’s immune system appears to mistakenly attack areas of the brain, causing sudden and dramatic changes in behaviour and movement.
The Three Key Words: Sudden, Dramatic, Dated
The most important thing to understand about true PANDAS is the word SUDDEN. Not gradually getting worse. Not a bad term at school. Parents should be able to tell you which week — sometimes which day — that everything changed. That clarity of onset is the defining feature that separates PANDAS from everything else.
The Five Diagnostic Criteria — Every One Is Required
PANDAS was first described by Dr Susan Swedo at the US National Institute of Mental Health in 1998. Five specific criteria must ALL be present. This is not a tick-some-boxes situation.
- OCD or Tic Disorder. The obsessions, compulsions, or tics must be severe enough to meet full medical criteria. ADHD alone, anxiety alone, or behaviour changes alone do NOT qualify.
- Child’s Age. Symptoms must first appear between the ages of 3 years and puberty. Onset after puberty effectively excludes PANDAS.
- Sudden, Dramatic Onset. This is the most critical criterion. Parents can identify the specific week or day. Not “gradually worse.” A sudden, unmistakeable change that feels like a switch being flipped.
- Proven Strep Link. There must be a documented, confirmed Group A streptococcal infection with a clear time relationship. A single elevated blood antibody test is NOT sufficient.
- Associated Neurological Signs. These include specific choreiform movements, hyperactivity, emotional lability, and sensory sensitivities — all appearing suddenly alongside the main symptoms.
True PANDAS follows an episodic course. Symptoms flare dramatically with each new strep infection and genuinely improve between episodes. If your child’s difficulties are constant and chronic rather than clearly episode-linked, PANDAS becomes much less likely.
Understanding the Blood Tests
The ASO (anti-streptolysin O) test is one of the most misunderstood aspects of the PANDAS conversation. An elevated ASO does NOT diagnose PANDAS. Here’s why:
- 15–20% of all school-age children have elevated ASO levels at any given time. It simply means they’ve encountered strep recently.
- 56% of children wrongly diagnosed with PANDAS also had elevated ASO. A positive test does not confirm PANDAS.
- ASO levels can remain elevated for months after a routine strep infection — long after the infection has cleared.
- A single elevated ASO is meaningless in isolation. You need sequential tests to demonstrate a rising pattern.
What a Proper Strep Investigation Looks Like
If PANDAS is genuinely being considered, the correct approach requires sequential testing:
- A throat swab (rapid test and 48-hour culture) looking for active strep
- A perianal swab if throat swabs are negative (strep can live there with minimal symptoms)
- A baseline ASO antibody level at the time of symptom onset
- A SECOND antibody test 6 to 8 weeks later, looking for a fourfold rise in levels
- That magnitude of rise is what genuinely suggests a recent infection caused the symptoms
Some families are directed to a commercially available test called the Cunningham Panel, which costs several thousand rands and is not covered by most medical aids in South Africa. The Cunningham Panel is not validated as a diagnostic test for PANDAS by the international medical community. It has a meaningful false-positive rate in children with ADHD, OCD, and Tourette’s. It is a research tool being sold as a clinical one.
ADHD with Tics vs Tourette’s vs PANDAS — Side by Side
| Feature | ADHD with Tics | Tourette Syndrome | True PANDAS |
|---|---|---|---|
| How it starts | Gradual, over months to years | Gradual, onset age 5–7 | Sudden — parents know the exact week |
| How common? | 1 in 5 children with ADHD | 1 in 150–200 children | 1 in 11,765 children |
| Infection link? | None | None | Yes — confirmed strep required |
| OCD features? | Mild or absent | Moderate, part of pattern | Prominent and sudden — dominant feature |
| Course over time | Chronic, fluctuates with stress | Improves through teen years | Episodes linked to each new strep infection |
| Family history? | Often ADHD in family | Often tics in family | Not required |
| Emotion changes? | ADHD-related, gradual | Related to OCD/anxiety | Extreme, sudden, dramatically out of character |
Why PANDAS Gets Over-Diagnosed — And Why This Matters
I want to address this fairly, because the answer isn’t always as simple as poor practice.
PANDAS offers something psychologically compelling: a specific medical cause, a treatment that feels decisive (antibiotics), and a story that removes parental guilt. In a busy consulting room, with a distressed family and a struggling child, the pressure to offer an explanation is real. These things are powerful even when the diagnosis is wrong.
- Unnecessary antibiotics carry real risks — gut disruption, resistance, allergic reactions
- More intensive treatments (steroids, intravenous immunoglobulin, plasma exchange) carry substantial risks
- Every month on the wrong path is a month not spent on interventions that would genuinely help your child
- Families spend significant money on tests and treatments that may be misdirected
PANDAS Is NOT the Right Investigation When:
- The onset was gradual, not sudden and dramatic
- There was no confirmed strep infection — only a single elevated ASO
- The diagnosis was made primarily because your child has ADHD and tics
- OCD features are absent, mild, or developed gradually
- Tourette’s syndrome and ADHD with tics were not properly assessed and excluded first
If your child has received a PANDAS diagnosis and something feels wrong, you are not being difficult. Consider a second opinion if the onset was gradual, there was no confirmed strep, or if ADHD with tics and Tourette’s were not properly assessed first. Getting the right diagnosis matters because the right treatment changes everything.
What Makes Tics Worse — And What Makes Them Better
This is one of the most practical sections in this guide. Understanding the everyday factors that influence tic severity gives you real power to help your child.
Caffeine — Coffee, tea, energy drinks, Coke, Pepsi, chocolate drinks. The most common tic trigger, more potent than ADHD medication
Fatigue and poor sleep — Tired children tic more. Period
Trying to suppress tics — Creates a rebound effect. Tics come back stronger after suppression
Drawing attention to tics — “Stop doing that” increases self-consciousness and anxiety, worsening tics
Being over-scheduled — No recovery time after school. Too many extramurals, therapy appointments, and structured activities
Illness — Any viral illness or infection can temporarily increase tics
Screen overload — Extended screen time, particularly high-stimulation gaming
Boredom — Paradoxically, having nothing to do can increase tics too
Physical exercise — Regular movement — swimming, cycling, running, martial arts — helps burn off excess energy and reduce tic frequency
Good sleep — Consistent bedtime, calm wind-down routine, dark room, no screens before bed
Reduced caffeine — Eliminating caffeine resolves or reduces tics in over half of children within two weeks
Calm, predictable routines — Structure reduces anxiety, which reduces tics. Structure is love
Ignoring the tics — When nobody reacts, the tic-anxiety cycle doesn’t escalate
Adequate downtime — Protect at least one hour of unstructured free time daily
Relaxation techniques — Deep breathing, progressive muscle relaxation for older children
Time — Most tics improve naturally as children grow. Time is your strongest ally
There is no overnight fix for tics. Because tics wax and wane naturally, it takes weeks to months to know whether any intervention is genuinely working or whether you’re seeing a natural improvement cycle. Make one change at a time. Give it at least four to six weeks before judging. Keep a simple diary noting tic severity (1–10 scale) daily, so you can see genuine trends rather than relying on memory.
Medication & Tics — The Honest Guide
Let me address the medication question directly, because this is where parents lose the most sleep.
Will ADHD Medication Make Tics Worse?
Current evidence is clear: stimulant medications at normal doses do not cause tics. Large studies and published reviews confirm this. The old medication labels warning about tics were based on outdated understanding.
That said, stimulants may temporarily increase tics in a small number of children. The key word is temporarily. Give it four to six weeks before concluding medication has worsened tics.
The Treatment Approach Depends on What’s Bigger
Start with methylphenidate cautiously and monitor. Tics often stay stable or even improve as ADHD-related stress reduces. Don’t attribute tic changes to medication too quickly — remember the two-week wax-and-wane cycle.
Atomoxetine (Strattera) is an excellent choice. It treats ADHD without affecting tics, and some evidence suggests it may modestly improve them. A win on both fronts.
Clonidine (Dixarit) addresses both. It’s approved for both conditions. Its effect on ADHD is modest, but the dual benefit makes it valuable. It can be combined with a stimulant if needed. It also helps with sleep — a significant bonus.
“We’ve noticed tics since starting the medication. The medication is helping with focus and behaviour. Should we wait and see if the tics settle, or should we consider adjusting? What are our options?”
The 8-Step Action Plan — What to Do About Tics
- Don’t draw attention to the tics. This is the single most important advice. Telling your child to “stop it” is like telling them to stop sneezing. Suppressing tics creates a rebound effect — they come back stronger. If your child mentions it, acknowledge calmly: “I’ve noticed that. It’s just something your brain does sometimes. It’s nothing to worry about.”
- Cut out caffeine — today. Before you change anything medical, remove all caffeine. Coffee, tea, energy drinks, Coke, Pepsi, chocolate drinks. Caffeine is the most common tic trigger. More than half of children improve within two weeks of elimination. Start today.
- Manage stress actively. Build predictable routines. Give warnings before transitions. Identify stress hot spots in your child’s week. Protect downtime. A child scheduled from dawn to dusk has no recovery time. Something needs to give.
- Prioritise sleep. Consistent bedtime. Calm wind-down routine. No screens one hour before bed. Dark, cool room. Tired children tic more. This is non-negotiable.
- Don’t stop ADHD medication without guidance. If tics appear on medication, consult your prescriber before stopping. The medication may be providing enormous benefit. Stopping because of mild tics that will settle on their own could do more harm than good.
- Increase physical activity. Daily exercise — swimming, cycling, running, trampolining, martial arts — helps reduce tic frequency and burn off the restless energy that feeds tics. Aim for at least 30–60 minutes daily.
- Talk to your child’s school. Teachers need to know so they respond appropriately. Key messages: don’t draw attention to tics; don’t punish for ticcing; allow brief breaks if suppression is exhausting; understand tics may increase during tests.
- Know when to escalate. Seek further assessment when: tics interfere with daily functioning; tics cause significant social distress; complex vocal tics develop; tics are accompanied by intrusive thoughts or compulsive behaviours; or your child is becoming depressed or anxious because of the tics.
What to Say to Your Child — Exact Scripts
“You know how sometimes your leg kicks when the doctor taps your knee? Your brain sends a signal and your body just does it. Tics are a bit like that. Your brain sends little signals and your body moves or makes a sound. You’re not doing anything wrong. It’s just how your brain works right now.”
“I know it feels awkward sometimes. But here’s the thing — most people don’t notice as much as you think they do. And the people who matter won’t care. We’re going to work through this together.”
“Some kids might ask about it. You can say: ‘It’s called a tic. My brain sends signals and my body moves. It’s no big deal.’ You don’t owe anyone a long explanation.”
“Trying to hold them in is exhausting, isn’t it? It’s like trying not to blink. You can do it for a bit, but eventually you have to blink. It’s okay to let them happen. They’ll settle down on their own.”
⚡ Quick Win Tonight
Do one thing tonight: look at your child’s diet and identify every source of caffeine. Coke, Pepsi, iced tea, energy drinks, coffee, and chocolate drinks. Remove them. Replace with water, juice, or caffeine-free alternatives.
This single change, costing you nothing and requiring no doctor’s appointment, resolves or reduces tics in more than half of children within two weeks.
Start tonight. Assess in two weeks. You might be surprised.
Remember This
Your child’s tics are not dangerous. They’re not a sign of something sinister. They’re not your fault. And in the majority of cases, they will improve with time.
One in five children with ADHD develops tics. This is common ground, not uncharted territory. The conditions that travel alongside tics — anxiety, OCD, learning difficulties, sleep problems — often matter more for your child’s daily life than the tics themselves. Make sure the full picture is being addressed, not just the most visible piece.
Your child’s brain isn’t broken. It’s wired differently. The tics are just one part of a bigger picture that, with the right understanding and the right support, gets clearer every day.
Progress, not perfection. You’ve got this.